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rate remain stable, even with variation of up to 30% of total blood volume.594 Right heart catheterization can be used to continuously measure central venous pressure and/or pulmonary artery pressure, pulmonary artery wedge pressure (as a reflection of LV diastolic pressure), and cardiac output. However, these are static variables that do not reliably reflect the CV filling status, and have been shown to accurately guide fluid therapy in 50% of patients.595 While routine use of pulmonary catheterization is discouraged during NCS, using dynamic variables, such as stroke volume variation or pulse pressure variation, has become the gold standard. In addition, TEE is increasingly being used as an intra-operative monitoring technique in major surgery in cardiac compromised patients and during cardiac surgery. Decisions on the extent of peri-operative monitoring and implementation of specific strategies during NCS should always be based on an individual patient-directed assessment, taking into consideration the severity of surgery and the patient’s physical condition. Basic peri-operative monitoring of the respiratory system consists of pulse oximetry and capnography; both methods are noninvasive and easily applicable. Pulse oximetry enables in vivo measurement of arterial oxygen saturation, and capnometry measures endtidal carbon dioxide concentration during inspiration and expiration; these monitors also provide information about the global haemodynamic status. Patients, independent of the anaesthetic technique and information provided by the different monitoring systems, must be regularly controlled.596 In addition, blood loss and urine output should be checked, when appropriate, and overall clinical status.597 Special attention is required for the activation and setting of audible alarms, as inadequate use or failure to respond to intra-operative alarms may result in patient hazard and undesirable outcomes.598

7.2 Anaesthesia

The decision on the optimal peri-operative strategy should be based on close exchange of clinical information between anaesthesiologists, cardiologists, surgeons, and other relevant specialists. In addition, it is mandatory that any proposed strategy is presented to and discussed with the patient. An informed discussion with the patient describing the planned patient pathway and expectations during the pre-, peri-, and post-operative phases of care, and what to expect from staff and surroundings, should be given using a clear, concise, and simple description. The ESA published Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated Guideline from the European Society of Anaesthesiology in 2018.560 This current section focuses on issues that are specifically important to patients with CV risk factors and diseases, taking into account the most recent developments in peri-operative management of these patients.

7.2.1 Intra-operative haemodynamics

Most anaesthetic techniques reduce sympathetic tone, leading to a decrease in venous return due to increased compliance of the venous system, vasodilatation, and decreased BP. Therefore, maintenance of adequate organ flow and perfusion pressure is of key importance in anaesthesiological management, especially in the CV-compromised patient. The importance of keeping stable perioperative haemodynamics has been recognized for many years.599 In the past few years, several studies have focused on the relationship between intra-operative hypotension and post-operative patient outcome. A recent systematic review identified 42 studies looking at associations between various absolute and relative intra-operative hypotension definitions and post-operative adverse outcomes after NCS.214 The reported associations suggest that organ injury (myocardial injury, stroke, AKI) might occur when the mean arterial pressure decreases to ,80 mmHg for ≥10 min, and that this risk increases with BP becoming progressively lower. However, most of the included studies had a retrospective observational design with a large variability in patient characteristics. In addition, the definitions of intra-operative hypotension varied widely across included studies. A recent study on the incidence of intra-operative hypotension as a function of the chosen cut-off definition described 48 different definitions of intra-operative hypotension. When applying these definitions to a cohort of 15 509 consecutive adult patients undergoing NCS under general anaesthesia, any episode of systolic BP ,80 mmHg was found in 41% of the patients, and 93% of the patients had at least one episode of systolic BP .20% below baseline. The relation between threshold values from the literature and incidence of intra-operative hypotension showed a sigmoidal shaped cumulative incidence curve, with intra-operative hypotension occurrence frequencies varying from 5–99%.600 It seems that no universal target BP to define intra-operative hypotension can currently be defined. In addition, in studies on intra-operative hypotension, both the threshold to define hypotension and the method chosen to model intra-operative hypotension affected the association of intra-operative hypotension with outcome.601 As a consequence, different studies on intra-operative hypotension are uncomparable and clinical conclusions on reported results remain hazardous. A recent expert consensus statement concluded that intra-operative mean arterial pressures ,60–70 mmHg are associated with myocardial injury, AKI, and death. These complications are a function of hypotension severity and duration.602 It remains to be established whether correction of intra-operative hypotension is also associated with improved post-operative outcome. To date, only one study has specifically addressed the question of whether an individualized BP management strategy reduces post-operative complications in a multicentre RCT including 292 patients. An individualized management strategy of targeting a systolic BP within 10% of the patient’s normal resting value resulted in significantly lower rates of post-operative organ dysfunction compared with standard practice (38.1% vs. 51.7%, respectively).528

These findings support the benefits of personalizing care, especially in surgical patients at high-risk of cardiac complications. It is important to underscore the importance of a physiopathological approach in understanding the underlying mechanisms of intra-operative hypotension, taking into account the extent and severity of the patient’s comorbidities; only then will a tailored treatment targeting the cause of intra-operative hypotension be possible (Figure 16). The severity of intra-operative hypotension is defined both by the threshold decrease from baseline and the duration of the hypotensive episode. The underlying mechanisms for intra-operative hypotension need to be identified: sympathicolysis with vasodilation, hypovolaemia, or other more complex causes such as peri-operative myocardial failure. Once the underlying mechanisms are identified, a targeted therapeutic strategy can be applied. This includes considering whether administration of specific chronic vasoactive medication such as ACEIs or ARBs should be interrupted 24 h prior to surgery.216

ESC Guidelines                                                                                                                                                                                     3891

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