New ESC guidelines for CV risk reduction in non-cardiac surgery

European Society of Cardiology (ESC) guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery have undergone extensive revision since the 2014 edition.

They still have the same goal – preventing bleeding complications associated with surgery, which is related to surgery myocardial infarction/ injury (PMI), stent thrombosis, acute heart failure, arrhythmia, pulmonary embolismStroke and cardiovascular death.

Co-chairs Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented the highlights from the guidance at European Society of Cardiology (ESC) Conference 2022 The document was simultaneously published online in European Heart Journal.

The document classifies non-cardiac surgery into three levels of 30-day risk of CV death, myocardial infarction, or stroke. Low risk includes (<1٪) جراحة العين أو الغدة الدرقية ؛ تشمل المخاطر المتوسطة (1٪ -5٪) استبدال الركبة أو الورك أو زرع الكلى ؛ وتشمل المخاطر العالية (> 5%) aortic aneurysms, lung transplantation, or surgery for pancreatic or bladder cancer (see more examples below).

Patients are classified as low-risk if they are younger than 65 years without CVD or CVD risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 years of age or older or have CV risk factors; And high risk if they have cardiovascular disease.

In an interview with theheart.org | Medscape Heart, Halvorsen, professor of cardiology, University of Oslo, Norway, focused on three important reviews:

First, recommendations for preoperative electrocardiograms (ECG) and biomarkers are more specific, he noted.

Guidelines suggest that prior to moderate or high-risk non-cardiac surgery, in patients with known cardiovascular disease and cardiovascular risk factors (including age 65 or older), or symptoms suggestive of CVD:

  • It is recommended that a 12-part EKG be obtained prior to surgery (Category I)

  • It is recommended to measure high sensitivity cardiac troponin (hs-cTn T) or high sensitivity cardiac troponin (hs-cTn I). It is also recommended that these biomarkers be measured at 24 hours and 48 hours after surgery (Class I)

  • It should be considered B-type natriuretic peptide (BNP) or N-terminal-pro-BNP (NT-proBNP)

However, for low-risk patients undergoing low- and moderate-risk non-cardiac surgery, routinely obtaining a preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP (class III) is not recommended.

Halvorsen explained that Troponins have a stronger Class I recommendation than IIA’s recommendation for BNP, as they are useful for preoperative risk stratification and for diagnosing PMI. She noted that “patients receive painkillers after surgery and may not experience pain,” but they may have PMI, which is a poorly prognosticated one.

Second, the guidelines recommend that “all patients should stop smoking 4 weeks prior to non-cardiac (Category 1) surgery,” she noted. Doctors should also “measure hemoglobin, and if the patient is anemic, the anemia should be treated.”

Third, the sections on anticoagulant therapy were significantly revised. “Bridging — stopping an oral anticoagulant drug and switching to a drug subcutaneously or intravenously — has been common, but recently we have new evidence that in most cases it increases the risk of bleeding,” Halverson said.

“we [now] More restrictive with regard to bridging “with unfragmented” heparin or low molecular weight heparin. “We recommend that bridges not be performed in patients with a low to moderate risk of thrombosis,” and bridgework should only be considered in patients with prosthetic heart valves or at a very high risk of thrombosis.

More recommendations before surgery

In a guidelines overview session at the conference, Halverson highlighted some new recommendations for preoperative risk assessment.

If time permits, it is recommended to improve the treatment recommended by the CVD guidelines and to control heart cancer risk factors including blood pressure, dyslipidemia, and diabetes, prior to non-cardiac (class I) surgery.

She noted that patients typically present with “bloating, chest pain, shortness of breath, and edema that may indicate severe cardiovascular disease, but may also be due to non-cardiac disease.” The guidelines state that “for patients with newly discovered murmurs And the Symptoms or signs of CVD, transthoracic echocardiography Recommended before non-cardiac (class I) surgery.

“Many studies have been done to try to see if starting certain medications before surgery can reduce the risk of complications,” Halverson noted. However, few of them have shown any benefit and “the issue of initiating pre-treatment with beta-blockers has been much debated,” she said. We reviewed the literature again and concluded that ‘routine initiation of perioperative beta-blockers is not recommended (Class IIIA). “”

“We adhere to the guidelines for acute and chronic coronary syndromes that recommend dual antiplatelet therapy for 6-12 months as standard before elective surgery,” she said. “However, in the case of time-sensitive surgery, the duration of this treatment can be shortened to at least 1 month after elective PCI and at least 3 months after PCI and ACS.”

Patients with certain types of cardiovascular disease

Moheli, Professor at Landshut Hospital Ashdorf, Landshut, Germany, highlighted some of the new guiding recommendations for patients with certain types of cardiovascular disease.

coronary heart disease (Bastard – villain). “For chronic coronary syndrome, cardiac screening is recommended only for patients who are undergoing medium-risk or high-risk non-cardiac surgery.”

Stress imaging should be considered prior to any high-risk non-cardiac surgery in asymptomatic patients with impaired functional capacity, early PCI or coronary artery bypass grafting (New Recommendation, Category IIa). “

Mitral valve regurgitation. For patients undergoing non-scheduled cardiac surgery, who remain symptomatic despite targeted medical treatment for mitral valve regurgitation (including resynchronization and revascularization of the myocardium), consider valve intervention—either by catheterization or surgery. Before non-cardiac surgery in eligible patients with acceptable procedural risks (new recommendation).

Heart implantable electronic devices (CIED). For high-risk patients undergoing non-cardiac surgery with a high potential for electromagnetic interference, CIED screening and necessary reprogramming should be considered immediately prior to the procedure (new recommendation).

Arrhythmia. “Meheli said, I just want to stress the infected patients atrial fibrillation With severe or worsening hemodynamic instability subject to non-cardiac surgery, emergency electrical cardioversion (class I) is recommended. “

Peripheral Artery Disease (PAD) and Aortic aneurysm . For these patients, “we do not recommend routine referral for cardiac examinations. But we do recommend them for patients with reduced functional capacity or with significant risk factors or symptoms (new recommendations)”.

Chronic arterial hypertension. “We have modified the recommendation, recommended avoidance of large perioperative fluctuations in blood pressure, and do not recommend postponing non-cardiac surgery for patients with stage I or II hypertension,” she said.

Cardiovascular complications after surgery

Moheli noted that the most common cardiovascular complication after surgery is PMI.

“In the BASEL-PMI registry, the incidence of this perioperative complication of moderate or high-risk non-cardiac surgery was as high as 15% among patients over 65 years of age or with a history of coronary heart disease or peripheral arterial disease, making this type of Complications are really important to prevent, evaluate, and know how to treat.”

“It is recommended that you have a high awareness of perioperative cardiovascular complications, along with PMI monitoring in patients undergoing moderate or high-risk non-cardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.

Moheli said the guidelines define the PMI as “an increase in the hypersensitive troponin delta more than the normal upper level.” “It is different from that used in the base algorithm for non-STEMI acute coronary syndrome. “

Postoperative atrial fibrillation has been observed in 2%-30% of non-cardiac surgery patients in various registries, particularly in patients undergoing moderate or high-risk non-cardiac surgery.

“We propose an algorithm on how to prevent and treat this complication. I would like to point out that in patients with postoperative hemodynamic instability, emergency cardioversion is indicated. For others, the rate is controlled with a target heart rate of less than 110. beats per minute.

In patients with postoperative atrial fibrillation, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, taking into account the expected net clinical benefit from oral anticoagulant therapy as well as patient preference. Enlightened (new recommendations).

The routine use of beta-blockers to prevent postoperative atrial fibrillation is not recommended in patients undergoing non-cardiac surgery.

The document also covers the management of patients with kidney disease, diabetes, cancer, obesity and COVID-19. In general, elective non-cardiac surgery should be postponed after a patient has been infected with COVID-19, until they have fully recovered, and their coexisting conditions are improved.

Instructions are available from the ESC website in several formats: Pocket Instructions, Pocket Instructions smartphone app, Instructions chipset, basic messages, and European Heart Journal Article – commodity.

Non-Cardiac Surgery Risk Categories

The guideline includes a table that classifies non-cardiac surgeries into three groups, based on the 30-day associated risk of death, myocardial infarction, or stroke:

  • Low (<1%): breast, dental, eye, thyroid, gynecological, orthopedic, and urological surgery.

  • Medium (1%-5%): Carotid surgery, aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, kidney transplantation, major gynecological surgery, orthopedics, or surgery Neurology (hip or spine), or urology

  • High (>5%): Aortic and major blood vessel surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), amputation, lung or liver transplant, pancreatic surgery, or bowel perforation repair.

The guidelines are approved by the European Society of Anesthesia and Intensive Care (ESAIC). Author disclosures are available at Supplementary document here.

European Society of Cardiology (ESC) Congress 2022. Overview of the guidelines August 26, 2022.

Your Heart c. Published August 26, 2022. guiding rules

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