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cardiac surgery (NCS) presented with at least two cardiovascular (CV) risk factors, 18% had coronary artery disease (CAD), 4.7% had a history of stroke, and 7.7% had a modified Revised Cardiac Risk Index (RCRI) score ≥3 (range 0–6) in 2012–13. These prevalence rates show a substantial increase compared with the equivalent rates in 2008–09.4 In a large registry including 37 915 consecutive patients undergoing percutaneous coronary interventions (PCIs) with drug-eluting stent (DES), the rates of NCS after PCI were 11% and 24%, 1 and 3 years after PCI respectively. The cut-off ages at which NCS was more likely to occur within 1 and 3 years of PCI were 62 and 73 years respectively.5 The prevalence of comorbidities, the clinical condition of patients before surgery, and the urgency, magnitude, type, and duration of the surgical procedure determine the risk of peri-operative complications. In a recent cohort study of 40 000 patients aged ≥45 years undergoing inpatient NCS, one of seven experienced a major cardiac or cerebrovascular complication at 30 days.6 Cardiovascular complications can particularly occur in patients with documented or asymptomatic coronary heart disease, left ventricular (LV) dysfunction, valvular heart disease (VHD), and arrhythmias, who undergo surgical procedures that are associated with prolonged haemodynamic and cardiac stress. In the case of peri-operative myocardial ischaemia, three mechanisms are important: (i) oxygen supply–demand mismatch on the background of coronary artery stenosis that may become flow-limiting by peri-operative haemodynamic fluctuations; (ii) acute coronary syndrome (ACS) due to stress-induced erosion or rupture of a vulnerable atherosclerotic plaque in combination with pro-inflammatory and hypercoagulable states induced by surgery, and the haemodynamic distress resulting from fluid shifts and anaesthesia; and (iii) surgery-associated bleeding risk requiring interruption of antiplatelet therapies, which might lead to stent thrombosis among patients undergoing NCS after recent coronary stent placement. Left ventricular dysfunction and arrhythmias may occur for various reasons at all ages. Because the prevalence of CAD, VHD, heart failure, and arrhythmias increases with age, perioperative CV mortality and morbidity are predominantly an issue in the adult population undergoing major NCS. In Europe, recent systematic data on the annual number and type of operations, and on patient outcomes are unfortunately lacking. Additionally, data definitions vary, as do data quantity and quality. Based on the estimates outlined above, nearly 6.6 million procedures are performed annually in European patients with CAD, peripheral artery disease (PAD), and cerebrovascular disease who are at high risk of CV complications. In a 7 day cohort study, the European Surgical Outcomes Study (EuSOS) group investigated the outcomes of NCS in 498 hospitals across 27 European nations and the UK; up to 8% of patients undergoing NCS required critical care admission, while in-hospital mortality ranged 1.4–21.5% (mean 4.0%), depending on safety precautions.7 In a recent prospective study of 2265 high-risk patients undergoing NCS in Switzerland, one out of five developed major adverse events within 365 days.8 When applied to the population in European Union countries, these figures translate into at least 660 000 major cardiac or cerebrovascular complications occurring annually due to NCS procedures. The 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing NCS focus on the pre-operative CV risk assessment and peri-operative management of patients in whom cardiovascular disease (CVD) is a potential source of complications during NCS.

2.3 Change in demographics

Within the next 30 years, the ageing of the population will have a major impact on peri-operative patient management. Patients undergoing NCS are older than the rest of the population. Furthermore, it is estimated that by 2030, one-fifth of individuals aged .75 years will undergo surgery each year. In addition, between 2018 and 2050, the number of people in Europe aged 75–84 years is projected to increase by ≏60%. The total number of surgical procedures may increase even faster because of the greater need for interventions with increasing age. Demographics of patients undergoing surgery show trends towards increasing numbers of elderly patients and increasing numbers of patients with comorbidities, particularly CVDs. Thus, adults aged ≥75 years have a greater risk of peri-operative major adverse cardiovascular events (MACEs) (9.5% vs. 4.8% for younger adults [P , 0.001]).9 However, age per se seems to be responsible for a small increase in the risk of complications; greater risks are associated with urgency and significant CV, pulmonary, and renal disease.

2.4 Purpose

As many years have passed and new evidence has become available since the publication of the 2014 ESC/European Society of Anaethesiology (ESA) Guidelines on non-cardiac surgery: cardiovascular assessment and management,10 the ESC has decided to revise the guidelines on NCS. These new guidelines are based on the 2014 edition, but all sections have been revised or rewritten, and several new sections have been added. Some of the old recommendations are unchanged or have been revised, and new recommendations have been added. These guidelines are intended for physicians, healthcare workers, and collaborators involved in the pre-operative, operative, and postoperative care of patients undergoing NCS. The objective is to endorse a standardized and evidence-based approach to peri-operative CV management. The guidelines recommend a stepwise evaluation of the patient that integrates clinical risk factors and test results with the estimated stress of the planned surgical procedure and the risks involved with the discontinuation of drugs. This results in an individualized risk assessment, with the opportunity of initiating medical therapy, coronary interventions, and specific surgical and anaesthetic techniques, or withholding medical therapy, in order to optimize the patient’s peri-operative condition. Further, it should be discussed in which institutions (specialized small hospital vs. tertiary care) the NCS will be performed. It is important that patients’ values and preferences with respect to the benefits and risks of surgery are taken into consideration, and that patients are involved in the decisions. This is particularly important when it comes to decisions about undergoing elective surgery or not, the timing of surgery, and choice of surgical and anaesthetic techniques. Compared with non-surgical settings, randomized controlled trials (RCTs) are scarce in this field. However, since the publication of the 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management there has been a significant increase in RCTs that are relevant in this setting. When no trials are available on a specific CV management regimen in the surgical setting, data from the non-surgical setting may be extrapolated and similar recommendations made, but with different levels of evidence. Downloaded from academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 07 October 2026