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degree of urgency of the NCS. Older patients have a higher risk than younger patients, and patients with a recent ACS have a higher risk than those with CCS. The presence of comorbidities may also influence the risk.

6.1.2 Pre-operative risk assessment and

management The diagnostic evaluation and pre-operative management of patients with CCS undergoing NCS are outlined in Section 4. In particular, the value of CCTA and ICA are discussed in Sections 4.5.3.1. and 4.5.3.2. In patients in need of immediate NCS, the operation must be performed without further delay and the time for pre-operative assessment is limited. In patients scheduled for elective NCS who present with an ACS, the management of ACS should follow the guidelines for ACS patients in the non-surgical setting.98,171 In such settings, it would be reasonable to consider treating the culprit lesion only before NCS. Potential changes in timing of surgery and the peri-operative management (e.g. type of surgery, anaesthesia, medical therapy, and perioperative monitoring) should be considered. In patients with known CAD, it is recommended to collect information regarding previous invasive and non-invasive diagnostic examinations, and therapeutic interventions for CAD, within a sufficient time interval before the NCS, ideally at the time the proposal for NCS is made.

6.1.3 Revascularization strategies

The indication for coronary revascularization depends on the clinical presentation of CAD (ACS vs. CCS), urgency, and cardiac risk of NCS. In general, there is clear evidence that routine revascularization improves outcomes in ACS patients and less support for such a strategy in patients with CCS. The process of decision-making related to revascularization in CCS should be individualized, in order to prioritize revascularization in case of involvement of a significant amount of ischaemic myocardium or refractory symptoms, while medical management is a valuable option in patients with less relevant CAD manifestations.

6.1.3.1 Chronic coronary syndromes

The rationale for coronary revascularization before NCS is to prevent peri-operative myocardial ischaemia leading to acute MI, haemodynamic instability, and arrhythmia. Data from autopsy studies following fatal peri-operative MI showed that more than two-thirds of the patients had significant left main or three-vessel disease.397 A retrospective registry based on the Coronary Artery Surgery Study (CASS) study found that coronary artery bypass graft (CABG) reduced the risk of peri-operative mortality and MI in patients undergoing major NCS, particularly in subjects with three-vessel disease and reduced left ventricular ejection fraction (LVEF).398 However, the evidence in support of routine prophylactic revascularization before NCS is based on relatively small clinical trials and retrospective registries unrepresentative of current clinical practice. In the Coronary Artery Revascularization Prophylaxis (CARP) trial, 510 patients with CCS were randomized to either optimal medical therapy or coronary revascularization (surgical or percutaneous) before major vascular surgery.399 In this study, patients receiving coronary revascularization compared with those who were medically treated did not differ in terms of acute MI after 30 days (8.4% vs. 8.4%, respectively) and mortality after 2.7 years (22% vs. 23%, respectively). Of note, this study excluded patients with significant left main disease, while one-third of the patients presented with three-vessel disease.399 In another randomized trial, 426 patients without evidence of CAD and scheduled for CEA were randomized to either routine coronary angiography with provisional revascularization before CEA or CEA without previous coronary angiography. There were no significant differences between the treatment groups in all-cause mortality, acute MI, and stroke at 30 days.172 A subsequent meta-analysis including 3949 patients showed no clinical benefit associated with routine prophylactic revascularization before NCS.400 A recent retrospective analysis on 4414 patients undergoing total joint arthroplasty found that the risk of adverse CV events was increased in patients with CAD, regardless of coronary revascularization before surgery. However, in patients receiving coronary revascularization, the risk of adverse CV events decreased, as the interval between revascularization and total joint arthroplasty was .2 years.401

The lack of evidence in support of routine prophylactic revascularization in CCS does not preclude a decision-process based on individual risk–benefit assessment in patients with a significant amount of ischaemic myocardium (as in the case of left main disease) and/or with refractory symptoms. The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial randomized 5179 patients with stable CAD and moderate or severe ischaemia to an initial invasive strategy (consisting of angiography plus revascularization, as appropriate) or to an initial strategy of medical therapy alone, with bail-out angiography if medical therapy failed.402 This trial did not find a significant difference in the primary composite end-point of death and MI between treatment groups. Interestingly, these neutral results were inapplicable to patients with severe left main disease, since these patients were excluded after a pre-randomization CCTA. It has yet to be demonstrated whether CCTA represents a valuable tool with which to select patients with stable CAD and/or moderate or severe ischaemia who might benefit from an initial invasive strategy. A large angiography-based registry of 9016 CCS patients with high-risk coronary anatomy (three-vessel disease with ≥70% stenosis in all three epicardial vessels or left main disease ≥50% stenosis) showed improved outcomes (all-cause mortality or MI) in patients undergoing revascularization (both for PCI or CABG) vs. conservative medical therapy (HR, 0.62; 95% CI, 0.58–0.66; P , 0.001).403 The 2018 ESC/EACTS Guidelines on myocardial revascularization and the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes generally apply to this population of patients, as long as the NCS can be postponed long enough to allow safe discontinuation of DAPT.146,404 Similarly, the choice between PCI and CABG should follow the general rules outlined in the above-mentioned guidelines.268,404 The use of intravascular imaging for planning and optimization of PCI is encouraged.405,406

6.1.3.2 Acute coronary syndromes

There are no trials specifically addressing the strategy of revascularization in ACS patients scheduled for NCS. High- and very high-risk Downloaded from academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 07 October 2026