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estimation in non-ischaemic heart diseases before NCS has yet to be studied. Myocardial perfusion imaging is particularly suitable if patients have poor acoustic windows for DSE. Meta-analyses of patients undergoing major NCS have demonstrated that, compared with fixed defects, reversible perfusion defects were associated with higher risk of cardiac death or non-fatal MI. The risk of cardiac events correlates with the extent of reversible perfusion abnormalities (severe: .20% of myocardium). Normal myocardial perfusion imaging in high-risk patients identifies a low-risk subgroup comparable with those without clinical risk factors for adverse cardiac outcomes.154,159,160 Stress cardiac magnetic resonance (CMR) imaging and late gadolinium enhancement are also accurate tools for detection of IHD and prognostication.166 4.5.3 Angiography 4.5.3.1. Coronary computed tomography angiography Coronary computed tomography angiography (CCTA) is recommended as an initial test for diagnosing CAD in stable patients with a low clinical likelihood or no previous diagnosis of CAD, and characteristics associated with a high likelihood of good image quality.146 In addition, CCTA is recommended as an alternative to invasive coronary angiography (ICA) for excluding non-ST-segment elevation acute coronary syndrome (NSTE-ACS) when there is low-to-intermediate likelihood of CAD, and when cardiac troponin and/or ECG are normal or inconclusive.98 The practical utility of CCTA is reduced when a high coronary calcium score is present.167 In patients undergoing NCS, the role of pre-operative CCTA to rule out CAD has been investigated in small- to medium-sized observational studies. The Coronary Computed Tomographic Angiography and Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (Coronary CTA VISION) trial prospectively investigated the incremental predictive value of CCTA over RCRI in 955 patients with a history of or risk factors for CAD, or a history of congestive HF undergoing NCS.168 Coronary computed tomography angiography improved the risk estimation for the primary outcome of post-operative CV death and non-fatal MI within 30 days, although CCTA was associated with more than five times inappropriate risk overestimations among patients not experiencing the primary outcome. The predictive value of CCTA further improved when associated with non-invasive functional testing, such as myocardial perfusion imaging, with a positive and negative predictive value of 50% (95% CI, 21–79) and 100% (95% CI, 79–100), respectively.161 Coronary computed tomography angiography associated with additional functional assessment of coronary stenosis with fractional flow reserve (FFR) with computed tomography (CT) was able to identify functionally severe coronary stenosis in 57% of the asymptomatic patients with no history of cardiac disease undergoing carotid endarterectomy (CEA).169 In 135 asymptomatic patients with no history of cardiac disease undergoing peripheral vascular surgery, pre-operative FFR with CT facilitated the identification of functionally severe coronary stenosis in 53% of the patients. These patients benefited from further revascularization, with a 1 year lower rate of CV death and MI.170 4.5.3.2 Invasive coronary angiography There is a lack of information from RCTs relating to the usefulness of ICA in patients scheduled for NCS. Adopting an ICA assessment may also cause an unnecessary and unpredictable delay in an already planned surgical intervention, and adding an independent procedural risk to the overall risk. Despite the fact that CAD may be present in a significant number of patients requiring NCS, indications for preoperative coronary angiography and revascularization are similar to angiography indications in the non-surgical setting.98,146,171 Pre-operative treatment of patients with myocardial ischaemia, either medically or with intervention, is recommended. Recommendation Table 9 — Recommendations for stress imaging Recommendations Classa Levelb Stress imaging is recommended before high-risk elective NCS in patients with poor functional capacityc and high likelihood of CADd or high clinical risk.e,146,156–158 I B Stress imaging should be considered before high-risk NCS in asymptomatic patients with poor functional capacity,d and previous PCI or CABG.147 IIa C Stress imaging may be considered before intermediate-risk NCS when ischaemia is of concern in patients with clinical risk factors and poor functional capacity.d,152,157,158 IIb B Stress imaging is not recommended routinely before NCS. III C © ESC 2022 CABG, coronary artery bypass graft; CAD, coronary artery disease; ECG, electrocardiogram; LV, left ventricular; NCS, non-cardiac surgery; PCI, percutaneous coronary intervention. aClass of recommendation. bLevel of evidence. cPhysical capacity based on Duke Activity Status Index (DASI) or inability to climb two flights of stairs. dPre-test probability .15% based on age, sex, and nature of symptoms, or two or more risk factors for CVD (dyslipidaemia, diabetes, hypertension, smoking, family history of CVD), or resting ECG changes (Q wave or ST-segment/T wave changes), or LV dysfunction suggestive of CAD.146 eOne or more clinical risk factor according to the Revised Cardiac Risk Index (ischaemic heart disease, cerebrovascular disease, history of congestive heart failure, serum creatinine level .2 mg/dL, diabetes requiring insulin therapy).46,47 Recommendation Table 10 — Recommendations for coronary angiography Recommendations Classa Levelb It is recommended to use the same indications for ICA and revascularization pre-operatively as in the non-surgical setting.98,146 I C CCTA should be considered to rule out CAD in patients with suspected CCS or biomarker-negative NSTE-ACS in case of low-to-intermediate clinical likelihood of CAD, or in patients unsuitable for non-invasive functional testing undergoing non-urgent, intermediate-, and high-risk NCS. IIa C Continued ESC Guidelines 3853 Downloaded from academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 07 October 2026