2022 ESC Guidelines on cardiovascular
assessment and management of patients
undergoing non-cardiac surgery
Developed by the task force for cardiovascular assessment and
management of patients undergoing non-cardiac surgery of the
European Society of Cardiology (ESC)
Endorsed by the European Society of Anaesthesiology and
Intensive Care (ESAIC)
Authors/Task Force Members: Sigrun Halvorsen *† (Chairperson) (Norway),
Julinda Mehilli *† (Chairperson) (Germany), Salvatore Cassese** (Task Force
Coordinator) (Germany), Trygve S. Hall** (Task Force Coordinator) (Norway),
Magdy Abdelhamid (Egypt), Emanuele Barbato (Italy/Belgium), Stefan De Hert1
(Belgium), IngriddeLaval (Sweden), TobiasGeisler (Germany), LynneHinterbuchner
(Austria), Borja Ibanez (Spain), Radosław Lenarczyk (Poland), Ulrich R. Mansmann
(Germany), Paul McGreavy (United Kingdom), Christian Mueller (Switzerland),
ClaudioMuneretto (Italy), AlexanderNiessner (Austria), Tatjana S. Potpara (Serbia),
Arsen Ristić (Serbia), L. Elif Sade (United States of America/Turkey),
Henrik Schirmer (Norway), Stefanie Schüpke (Germany), Henrik Sillesen
(Denmark), Helge Skulstad (Norway), Lucia Torracca (Italy), Oktay Tutarel
(Germany), Peter Van Der Meer (Netherlands), Wojtek Wojakowski (Poland),
Kai Zacharowski1 (Germany), and ESC Scientific Document Group
* Corresponding authors: Sigrun Halvorsen, Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway, and University of Oslo, Oslo, Norway. Tel.: +47 91317460.
E-mail: sigrun.halvorsen@medisin.uio.no.
Julinda Mehilli, Department: Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany, Klinikum der Universität München, Ludwig-Maximilians-Universität and German Centre
for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany. Tel.: +49 871 4042782. E-mail: Julinda.mehilli@lakumed.de
† The two chairpersons contributed equally to the document and are joint corresponding authors.
** The two Task Force Coordinators contributed equally to the document
Author/Task Force Member affiliations: listed in author information.
1Representing the European Society of Anaesthesiology and Intensive Care (ESAIC)
ESC Clinical Practice Guidelines (CPG) Committee listed in the Appendix.
ESC subspecialty communities having participated in the development of this document:
Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular
Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), and Heart Failure Association (HFA).
Councils: Council of Cardio-Oncology and Council on Valvular Heart Disease.
Working Groups: Adult Congenital Heart Disease, Aorta and Peripheral Vascular Diseases, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, and Thrombosis.
Patient Forum
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC
Guidelines may be translated or reproduced in any formwithout written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University
Press, the publisher of the European Heart Journal, and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@oup.com).
European Heart Journal (2022) 43, 3826–3924
https://doi.org/10.1093/eurheartj/ehac270
ESC GUIDELINES
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Document-Reviewers: Juhani Knuuti, (CPG Review Coordinator) (Finland), Steen Dalby Kristensen, (CPG
Review Coordinator) (Denmark), Victor Aboyans (France), Ingo Ahrens (Germany), Sotiris Antoniou (United
Kingdom), Riccardo Asteggiano (Italy), Dan Atar (Norway), Andreas Baumbach (United Kingdom),
Helmut Baumgartner (Germany), Michael Böhm (Germany), Michael A. Borger (Germany), Hector Bueno
(Spain), Jelena Čelutkienė (Lithuania), Alaide Chieffo (Italy), Maya Cikes (Croatia), Harald Darius (Germany),
Victoria Delgado (Spain), Philip J. Devereaux (Canada), David Duncker (Germany), Volkmar Falk (Germany),
Laurent Fauchier (France), Gilbert Habib (France), David Hasdai (Israel), Kurt Huber (Austria), Bernard Iung
(France), Tiny Jaarsma (Sweden), Aleksandra Konradi (Russian Federation), Konstantinos C. Koskinas
(Switzerland), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Basil S. Lewis (Israel), Ales Linhart
(Czech Republic), Maja-Lisa Løchen (Norway), Michael Maeng (Denmark), StéphaneManzo-Silberman (France),
Richard Mindham (United Kingdom), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark),
Steffen E. Petersen (United Kingdom), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Antti Saraste
(Finland), Dirk Sibbing (Germany), Jolanta Siller-Matula (Austria), Marta Sitges (Spain), Ivan Stankovic (Serbia),
Rob F. Storey (United Kingdom), Jurrien ten Berg (Netherlands), Matthias Thielmann (Germany), and
Rhian M. Touyz (Canada/United Kingdom)
All experts involved in the development of these guidelines have submitted declarations of interest. These have
been compiled in a report and simultaneously published in a supplementary document to the guidelines. The
report is also available on the ESC website www.escardio.org/Guidelines
See the European Heart Journal online for supplementary data that include background information and
detailed discussion of the data that have provided the basis of the guidelines.
Click here to access the corresponding ESC CardioMed chapters.
Keywords Guidelines • Non-cardiac surgery • Pre-operative cardiac risk assessment • Pre-operative cardiac testing •
Biomarkers • Pre-operative coronary artery revascularization • Peri-operative cardiac management •
Anti-thrombotic therapy • Peri-operative beta-blockers • Pre-operative treatment of valvular disease • Peri-operative
treatment of arrhythmias • Post-operative cardiac surveillance • Peri-operative myocardial injury/infarction
Table of contents
1. Preamble ........................................................................................................ 3832
2. Introduction ................................................................................................. 3834
2.1. What is new ........................................................................................ 3834
2.2. The magnitude of the problem ................................................... 3839
2.3. Change in demographics ................................................................ 3840
2.4. Purpose .................................................................................................. 3840
2.5. The outcomes we want to prevent .......................................... 3841
3. Clinical risk evaluation .............................................................................. 3841
3.1. Surgery-related risk .......................................................................... 3841
3.1.1. Timing of surgery ...................................................................... 3842
3.2. Type of surgical approach ............................................................. 3842
3.2.1. Laparoscopy ................................................................................ 3842
3.2.1.1. Vascular and endovascular procedures ................... 3843
3.2.1.2. Video-assisted non-cardiac surgery ........................... 3843
3.3. Patient-related risk ............................................................................ 3843
3.3.1. Initial assessment ....................................................................... 3843
3.3.1.1. Patients aged ,65 years without a history of
cardiovascular disease or cardiovascular risk factors ........ 3843
3.3.1.2. Patients aged≥65 years or with cardiovascular risk
factors .................................................................................................... 3843
3.3.1.3. Patients with established cardiovascular disease . 3844
3.3.2. Patients with murmurs, chest pain, dyspnoea, or
peripheral oedema ............................................................................... 3845
3.3.2.1. Murmurs ............................................................................... 3845
3.3.2.2. Chest pain ............................................................................ 3845
3.3.2.3. Dyspnoea .............................................................................. 3845
Disclaimer: The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the
time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC Guidelines and any other official recommendations
or guidelines issued by the relevant public health authorities, particularly in relation to good use of health care or therapeutic strategies. Health professionals are encouraged to take the
ESC Guidelines fully into account when exercising their clinical judgment, and in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies;
however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of
each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. The ESC Guidelines do not exempt health profes-
sionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage
each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the
applicable rules and regulations relating to drugs and medical devices at the time of prescription.
© The European Society of Cardiology 2022. All rights reserved. For permissions please e-mail: journals.permissions@oup.com
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3.3.2.4. Peripheral oedema ........................................................... 3845
3.4. Timing of adequate risk evaluation ............................................ 3846
3.5. Avoidance or allowance for surgery in the individual patient 3846
3.6. The patient perspective .................................................................. 3846
4. Pre-operative assessment tools ........................................................... 3847
4.1. Risk scores ............................................................................................ 3847
4.1.1. General risk calculators .......................................................... 3847
4.1.2. Frailty .............................................................................................. 3849
4.2. Functional capacity ............................................................................ 3849
4.3. Electrocardiography ......................................................................... 3850
4.4. Biomarkers ........................................................................................... 3850
4.5. Non-invasive and invasive procedures ..................................... 3851
4.5.1. Resting transthoracic echocardiography ......................... 3851
4.5.2. Stress tests ................................................................................... 3852
4.5.2.1. Exercise stress test ........................................................... 3852
4.5.2.2. Stress imaging ..................................................................... 3852
4.5.3. Angiography ................................................................................ 3853
4.5.3.1. Coronary computed tomography angiography ... 3853
4.5.3.2. Invasive coronary angiography .................................... 3853
5. General risk-reduction strategies ........................................................ 3854
5.1. Cardiovascular risk factors and lifestyle interventions ...... 3854
5.2. Pharmacological ................................................................................. 3854
5.2.1. Beta-blockers .............................................................................. 3854
5.2.2. Amiodarone ................................................................................ 3855
5.2.3. Statins ............................................................................................ 3855
5.2.4. Renin–angiotensin–aldosterone system inhibitors ..... 3855
5.2.5. Calcium channel blockers ...................................................... 3855
5.2.6. Alpha-2 receptor agonists .................................................... 3856
5.2.7. Diuretics ....................................................................................... 3856
5.2.8. Ivabradine ..................................................................................... 3856
5.2.9. Sodium–glucose co-transporter-2 inhibitors ................ 3856
5.3. Peri-operative handling of antithrombotic agents ............... 3857
5.3.1. Antiplatelets ................................................................................ 3857
5.3.1.1. Single antiplatelet therapy ............................................. 3857
5.3.1.2. Dual antiplatelet therapy ............................................... 3860
5.3.1.3. De-escalation of antiplatelet effect ............................ 3862
5.3.1.4. Platelet function guided peri-operative
management of antiplatelet therapy ......................................... 3862
5.3.2. Oral anticoagulants .................................................................. 3863
5.3.2.1. Vitamin K antagonists ...................................................... 3863
5.3.2.1.1. Vitamin K antagonists in patients with
mechanical heart valves ............................................................. 3863
5.3.2.1.2. Vitamin K antagonists for atrial fibrillation/
venous thromboembolism ....................................................... 3864
5.3.2.1.3. Restarting vitamin K antagonists after invasive
procedures or surgery ............................................................... 3864
5.3.2.1.4. Reversal of vitamin K antagonists ...................... 3864
5.3.2.2. Non-vitamin K antagonist oral anticoagulants ...... 3864
5.3.2.2.1. Unplanned surgery in patients on non-vitamin
K antagonist oral anticoagulants and reversal for
emergency procedures .............................................................. 3864
5.3.2.2.2. Planned interventions in patients on non-
vitamin K oral anticoagulants .................................................. 3866
5.3.2.2.3. Bridging ......................................................................... 3866
5.3.2.2.4. Laboratory testing before surgery .................... 3866
5.3.2.2.5. Considerations for specific procedures .......... 3867
5.3.2.2.6.When to restart non-vitamin K antagonist oral
anticoagulants after interventions ......................................... 3868
5.3.2.3. Combination therapy (antiplatelet and
anticoagulant) ...................................................................................... 3868
5.4. Peri-operative thromboprophylaxis .......................................... 3869
5.5. Patient blood management ........................................................... 3869
5.5.1. Pre-operative anaemia—diagnosis and treatment ..... 3870
5.5.2. Bleeding and reduction of iatrogenic diagnostic/
surgery-related blood loss ................................................................ 3870
5.5.3. Optimal blood component use with patient-centred
clinical decision support ..................................................................... 3871
6. Specific diseases .......................................................................................... 3871
6.1. Coronary artery disease ................................................................. 3871
6.1.1. Risk for patients with coronary artery disease ............ 3871
6.1.2. Pre-operative risk assessment and management ........ 3872
6.1.3. Revascularization strategies .................................................. 3872
6.1.3.1. Chronic coronary syndromes ...................................... 3872
6.1.3.2. Acute coronary syndromes .......................................... 3872
6.2. Chronic heart failure ........................................................................ 3874
6.2.1. Risk for patients with heart failure .................................... 3874
6.2.2. Pre- and post-operative management strategies ........ 3874
6.2.3. Hypertrophic obstructive cardiomyopathy ................... 3875
6.2.4. Patients with ventricular assist devices undergoing
non-cardiac surgery .............................................................................. 3875
6.3. Valvular heart disease ...................................................................... 3875
6.3.1. Risk for patients with valvular heart disease ................. 3875
6.3.2. Pre-operative management strategies and risk-
reduction strategy ................................................................................. 3876
6.3.2.1. Aortic valve stenosis ........................................................ 3876
6.3.2.2. Mitral valve stenosis ......................................................... 3877
6.3.2.3. Aortic valve regurgitation .............................................. 3878
6.3.2.4. Mitral valve regurgitation ............................................... 3878
6.3.2.5. Patients with prosthetic valve(s) ................................ 3878
6.3.2.6. Prophylaxis of infective endocarditis ........................ 3878
6.4. Known or newly diagnosed arrhythmias ................................ 3879
6.4.1. Peri-operative management—general measures ........ 3879
6.4.2. Supraventricular arrhythmias ............................................... 3879
6.4.3. Atrial fibrillation/flutter ........................................................... 3879
6.4.4. Ventricular arrhythmias ......................................................... 3879
6.4.5. Bradyarrhythmias ...................................................................... 3881
6.4.6. Management of patients with cardiac implantable
electronic devices .................................................................................. 3881
6.5. Adult congenital heart disease ..................................................... 3882
6.6. Pericardial diseases ........................................................................... 3883
6.7. Pulmonary disease and pulmonary arterial hypertension 3884
6.7.1. Pulmonary disease .................................................................... 3884
6.7.2. Pulmonary arterial hypertension ........................................ 3884
6.8. Arterial hypertension ....................................................................... 3885
6.9. Peripheral artery disease ................................................................ 3886
6.9.1. Peripheral artery disease and non-vascular non-cardiac
surgery ....................................................................................................... 3886
6.9.2. Peripheral artery disease and vascular non-cardiac
surgery ....................................................................................................... 3886
6.10. Cerebrovascular disease .............................................................. 3887
6.11. Renal disease ..................................................................................... 3887
6.12. Obesity ................................................................................................ 3888
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6.13. Diabetes .............................................................................................. 3889
6.14. Cancer ................................................................................................. 3889
6.15. Coronavirus disease 2019 ........................................................... 3889
7. Peri-operative monitoring and anaesthesia .................................... 3890
7.1. Peri-operative monitoring ............................................................. 3890
7.2. Anaesthesia .......................................................................................... 3891
7.2.1. Intra-operative haemodynamics ......................................... 3891
7.2.2. Choice of anaesthetic agent ................................................. 3892
7.3. Locoregional techniques ................................................................ 3892
7.4. Peri-operative goal-directed haemodynamic therapy ....... 3893
7.5. Post-operative management ......................................................... 3893
8. Peri-operative cardiovascular complications .................................. 3893
8.1. Peri-operative myocardial infarction/injury ............................ 3894
8.2. Spontaneous myocardial infarction (after day 2) ................ 3897
8.3. Takotsubo syndrome ....................................................................... 3897
8.4. Acute heart failure ............................................................................ 3897
8.5. Venous thromboembolism ........................................................... 3897
8.6. Atrial fibrillation and other relevant arrhythmias ................ 3897
8.6.1. Prevention of post-operative atrial fibrillation ............. 3897
8.6.2. Management of post-operative atrial fibrillation ......... 3898
8.6.2.1. Rate and/or rhythm control ......................................... 3898
8.6.2.2. Prevention of atrial fibrillation-related
thromboembolic complications .................................................. 3899
8.7. Peri-operative stroke ....................................................................... 3899
9. Key messages ............................................................................................... 3900
10. Gaps in evidence ...................................................................................... 3900
11. Sex differences ......................................................................................... 3901
12. ‘What to do’ and ‘what not to do’ messages from the
Guidelines ........................................................................................................... 3901
13. Quality indicators .................................................................................... 3906
14. Central illustration .................................................................................. 3906
15. Supplementary data ................................................................................ 3907
16. Data availability statement ................................................................... 3907
17. Author information ................................................................................ 3907
18. Appendix ..................................................................................................... 3907
19. References .................................................................................................. 3908
Tables of Recommendations
Recommendation Table 1 — Recommendations for selection of
surgical approach and impact on risk ..................................................... 3843
Recommendation Table 2 — Recommendations for all patients
scheduled for non-cardiac surgery .......................................................... 3845
Recommendation Table 3 — Recommendations for patients
aged ,65 years without signs, symptoms, or history of
cardiovascular disease ................................................................................... 3845
Recommendation Table 4 — Recommendations for
pre-operative assessment in patients with previously unknown
murmur, angina, dyspnoea, or peripheral oedema .......................... 3845
Recommendation Table 5 — Recommendations for patient
information ........................................................................................................ 3847
Recommendation Table 6 — Recommendations for
pre-operative assessment of frailty and functional capacity ......... 3849
Recommendation Table 7 — Recommendations for
pre-operative risk assessment—electrocardiography and
biomarkers ......................................................................................................... 3851
Recommendation Table 8 — Recommendations for
transthoracic echocardiography ............................................................... 3852
Recommendation Table 9— Recommendations for stress imaging 3853
Recommendation Table 10 — Recommendations for coronary
angiography ........................................................................................................ 3853
Recommendation Table 11— Recommendations for lifestyle and
cardiovascular risk factors ........................................................................... 3854
Recommendation Table 12 — Recommendations for
pharmacological treatment ......................................................................... 3856
Recommendation Table 13 — Recommendations for use of
antiplatelet therapy in patients undergoing non-cardiac surgery 3862
Recommendation Table 14 — Recommendations for
interruption and resumption of anticoagulants in patients
undergoing non-cardiac surgery ............................................................... 3868
Recommendation Table 15 — Recommendations for
thromboprophylaxis ...................................................................................... 3869
Recommendation Table 16 — Recommendations for intra- and
post-operative complications associated with anaemia ................. 3870
Recommendation Table 17 — Recommendations for intra- and
post-operative complications associated with blood loss ............. 3871
Recommendation Table 18 — Recommendations for intra- and
post-operative complications associated with allogeneic blood
transfusion .......................................................................................................... 3871
Recommendation Table 19 — Recommendations for the timing
of non-cardiac surgery and revascularization in patients with
known coronary artery disease ................................................................ 3874
Recommendation Table 20 — Recommendations for
management of heart failure in patients undergoing non-cardiac
surgery ................................................................................................................. 3875
Recommendation Table 21 — Recommendations for
management of valvular heart disease in patients undergoing
non-cardiac surgery ........................................................................................ 3878
Recommendation Table 22 — Recommendations
for management of known or newly diagnosed arrhythmias ...... 3880
Recommendation Table 23 — Recommendations for
management of bradyarrhythmia and patients carrying cardiac
implantable devices ........................................................................................ 3882
Recommendation Table 24 — Recommendations for
management of patients with adult congenital heart disease
undergoing non-cardiac surgery ............................................................... 3883
Recommendation Table 25 — Recommendations for pericardial
diseases ................................................................................................................ 3884
Recommendation Table 26 — Recommendations for patients
with pulmonary arterial hypertension undergoing non-cardiac
surgery ................................................................................................................. 3885
Recommendation Table 27 — Recommendations for
pre-operative management of hypertension ...................................... 3886
Recommendation Table 28 — Recommendations for
management of patients with peripheral artery disease
and/or abdominal aortic aneurysm undergoing non-cardiac
surgery ......................................................................................................... 3887
Recommendation Table 29 — Recommendations for
management of patients with suspected or established carotid
artery disease undergoing non-cardiac surgery ................................. 3887
Recommendation Table 30 — Recommendations for
management of patients with renal disease undergoing
non-cardiac surgery ........................................................................................ 3888
Recommendation Table 31 — Recommendations for
management of patients with obesity undergoing non-cardiac
surgery ................................................................................................................. 3888
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Recommendation Table 32 — Recommendations for
management of patients with diabetes mellitus undergoing
non-cardiac surgery ........................................................................................ 3889
Recommendation Table 33 — Recommendations for
peri-operative monitoring and anaesthesia ......................................... 3893
Recommendation Table 34 — Recommendations for
peri-operative cardiovascular complications ....................................... 3899
List of tables
Table 1 Classes of recommendations .................................................... 3833
Table 2 Levels of evidence .......................................................................... 3833
Table 3 New concepts and sections in the current guidelines ... 3834
Table 4 What is new ..................................................................................... 3834
Table 4A New recommendations ........................................................... 3834
Table 4B Revised recommendations ...................................................... 3838
Table 5 Surgical risk estimate according to type of surgery or
intervention ....................................................................................................... 3842
Table 6 Risk score calculators ................................................................... 3848
Table 7 Pharmacokinetic and pharmacodynamic characteristics of
antiplatelets ........................................................................................................ 3857
Table 8 Pharmacokinetic and pharmacodynamic characteristics of
oral anticoagulants .......................................................................................... 3858
Table 9 Bleeding risk according to type of non-cardiac surgery 3858
Table 10 Laboratory parameters for the diagnosis of absolute
iron-deficiency anaemia ................................................................................ 3870
Table 11 Peri-operative approach to patients with ventricular
assist devices undergoing non-cardiac surgery ................................... 3875
Table 12 Peri-operative management of patients with arrhythmias 3880
Table 13 Risk stratification for non-cardiac surgery in adults with
congenital heart disease ............................................................................... 3883
Table 14 Patient-related and surgery-related factors to be
considered when assessing peri-operative risk in patients with
pulmonary arterial hypertension .............................................................. 3885
Table 15 Factors that could influence peri-operative risk during
cancer surgery and preventive strategies ............................................. 3890
List of figures
Figure 1 Total risk is an interaction of patient-related and
surgery-related risk ........................................................................................ 3841
Figure 2 Pre-operative assessment before non-cardiac surgery 3844
Figure 3 Examples of questions and concerns expressed by
patients ................................................................................................................ 3847
Figure 4 Recommended measurements to assess and detect the
risk of post-operative cardiac complications ...................................... 3850
Figure 5 Recommendations for management of antiplatelet
therapy in patients undergoing non-cardiac surgery ....................... 3859
Figure 6 P2Y12 inhibitor interruption after percutaneous
coronary intervention before elective non-cardiac surgery ......... 3860
Figure 7 Bridging with intravenous antiplatelet agents. ASA,
acetylsalicylic acid; FU, follow-up; LD, loading dose; NCS,
non-cardiac surgery; o.d., once a day ...................................................... 3861
Figure 8 Recommendations for management of oral
anticoagulation therapy in patients undergoing non-cardiac
surgery ................................................................................................................. 3863
Figure 9 Peri-operative management of non-vitamin K antagonist
oral anticoagulant according to the periprocedural risk of bleeding 3865
Figure 10 Timing of last non-vitamin K antagonist oral anticoagulant
dose before elective NCS according to renal function ...................... 3866
Figure 11 Suggested strategy for potential reversal of non-vitamin
K oral anticoagulants effect ........................................................................ 3867
Figure 12Management of patients with acute or chronic coronary
syndrome scheduled for non-cardiac surgery .................................... 3873
Figure 13 Management of patients with severe aortic valve
stenosis scheduled for non-cardiac surgery ........................................ 3876
Figure 14 Management of patients with secondary mitral valve
regurgitation scheduled for non-cardiac surgery .............................. 3877
Figure 15 Optimal location of return electrode during unipolar
electrosurgery in patients with cardiac implantable electronic
devices, depending on the surgery site .................................................. 3882
Figure 16 Pathophysiological approach to address intra-operative
hypotension ....................................................................................................... 3892
Figure 17 Factors associated with peri-operative cardiovascular
complications. SNS, sympathetic nervous system ............................ 3894
Figure 18 Differential diagnosis of elevated post-operative cardiac
troponin concentrations .............................................................................. 3895
Figure 19 Systematic work-up (aetiology) and therapy of
peri-operative myocardial infarction/injury .......................................... 3896
Figure 20 Prevention and management of post-operative atrial
fibrillation ............................................................................................................ 3898
Figure 21 Central illustration: the complex interplay between the
intrinsic risk of surgery and the patient risk of peri-operative
cardiovascular complications ..................................................................... 3906
Abbreviations and acronyms
AAA Abdominal aortic aneurysm
AAD Antiarrhythmic drug
ACEI Angiotensin-converting-enzyme
inhibitor
ACHD Adults with congenital heart disease
ACS Acute coronary syndrome
ACS NSQIP American College of Surgery National
Surgical Quality Improvement Program
AF Atrial fibrillation
AKI Acute kidney injury
aPTT Activated partial thromboplastin time
AR Aortic valve regurgitation
ARB Angiotensin receptor blocker
ARNI Angiotensin receptor neprilysin inhibitor
AS Aortic valve stenosis
ASA Acetylsalicylic acid
ASA–PS American Society of Anesthesiology
Physical Status
ASCVD Atherosclerotic cardiovascular disease
AUB-HAS2 American University of Beirut
(AUB)-HAS2
AUC Area under curve
AVR Aortic valve replacement
BAV Balloon aortic valvuloplasty
BCSH British Committee for Standards in
Haematology
b.i.d. Bis in die (twice a day)
BTKi Bruton tyrosine kinase inhibitors
BMI Body mass index
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BMS Bare metal stent
BNP B-type natriuretic peptide
BP Blood pressure
b.p.m. Beats per minute
BSA Body surface area
CABG Coronary artery bypass graft
CAD Coronary artery disease
CARP Coronary Artery Revascularization
Prophylaxis (trial)
CAS Carotid artery stenting
CASS Coronary Artery Surgery Study
CCB Calcium channel blocker
CCS Chronic coronary syndrome
CCTA Coronary computed tomography
angiography
CEA Carotid endarterectomy
CHA2DS2-VASc Congestive heart failure, hypertension,
age ≥75 years, diabetes mellitus, stroke,
vascular disease, age 65–74 years, sex
category (female)
CI Confidence interval
CIED Cardiac implantable electronic device
CK Creatinine kinase
CKD Chronic kidney disease
CKD-EPI Chronic Kidney Disease Epidemiology
Collaboration
Cmax Maximum serum concentration
CMR Cardiac magnetic resonance
COAPT Cardiovascular Outcomes Assessment
of the MitraClip Percutaneous Therapy
for Heart Failure Patients with
Functional Mitral Regurgitation (trial)
COPD Chronic obstructive pulmonary disease
CORIDA Per-procedural Concentration of Direct
Oral Anticoagulants (trial)
Coronary CTA VISION Coronary Computed Tomographic
Angiography and Vascular Events in
Noncardiac Surgery Patients Cohort
Evaluation (trial)
COVID-19 Coronavirus disease 2019
CPET Cardiopulmonary exercise testing
CRF Cardiorespiratory fitness
CRT Cardiac resynchronization therapy
CT Computed tomography
cTn T/I Cardiac troponin T/I
CTO Chronic total occlusion
CV Cardiovascular
CVD Cardiovascular disease
DAPT Dual antiplatelet therapy
DASI Duke Activity Status Index
DES Drug-eluting stent
DM Diabetes mellitus
DSE Dobutamine stress echocardiography
dTT Diluted thrombin time
EACTS European Association for
Cardio-Thoracic Surgery
ECG Electrocardiographic/electrocardiogram
EDKA Euglycaemic diabetic ketoacidosis
eGFR Estimated glomerular filtration rate
EMI Electromagnetic interference
EORP EURObservational Research
Programme
ESA European Society of Anaesthesiology
ESC European Society of Cardiology
ESH European Society of Hypertension
ESTS European Society of Thoracic
Surgeons
ESVS European Society for Vascular Surgery
EuSOS European Surgical Outcomes Study
EVAR Endovascular abdominal aortic aneurysm
repair
FDA US Food and Drug Administration
FFR Fractional flow reserve
FIIa Factor IIa
FOCUS Focused cardiac ultrasound
FXa Factor Xa
GDMT Guideline-directed medical therapy
GFR Glomerular filtration rate
HbA1c Glycated haemoglobin
HF Heart failure
HIP-ATTACK HIP Fracture Accelerated Surgical
TreaTment And Care tracK (trial)
HR Hazard ratio
hs-cTn High-sensitivity cardiac troponin
i.v. Intravenous
ICA Invasive coronary angiography
ICD Implantable cardioverter–defibrillator
ICU Intensive care unit
ID Iron deficiency
IHD Ischaemic heart disease
INR International normalized ratio
ISCHEMIA International Study of Comparative
Health Effectiveness with Medical and
Invasive Approaches (trial)
iwFR Instantaneous wave-free ratio
KDIGO Kidney Disease: Improving Global
Outcomes
LD Loading dose
LMWH Low molecular weight heparin
LOAD Lowering the Risk of Operative
Complications Using Atorvastatin
Loading Dose (trial)
LoE Level of evidence
LV Left ventricular
LVEF Left ventricular ejection fraction
LVESD Left ventricular end-systolic diameter
LVESDi Left ventricular end-systolic dimension
index
MACE Major adverse cardiovascular event
MET Metabolic equivalent
METS Measurement of Exercise Tolerance
before Surgery (trial)
MHV Mechanical heart valve
MI Myocardial infarction
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MINS Myocardial injury following non-cardiac
surgery
MR Mitral valve regurgitation
MS Mitral valve stenosis
NCS Non-cardiac surgery
NOAC Non-vitamin K antagonist oral
anticoagulant
NSAID Non-steroidal anti-inflammatory drug
NSTE-ACS Non-ST-segment elevation acute
coronary syndrome
NT-proBNP N-terminal pro-B-type natriuretic
peptide
NYHA New York Heart Association
OAC Oral anticoagulant
o.d. Omnie die (once a day)
OR Odds ratio
OSA Obstructive sleep apnoea
PA Pulmonary artery
PAD Peripheral artery disease
PAH Pulmonary arterial hypertension
PAUSE Perioperative Anticoagulant Use for
Surgery Evaluation (trial)
PBM Patient Blood Management
PCC Prothrombin complex concentrate
PCI Percutaneous coronary intervention
PE Pulmonary embolism
PMC Percutaneous mitral commissurotomy
PMI Peri-operative myocardial infarction/
injury
POISE PeriOperative ISchemic Evaluation Trial
PPC Prothrombin complex concentrate
PT Prothrombin time
PVC Premature ventricular contractions
QI Quality indicator
RAAS Renin−angiotensin−aldosterone system
RBC Red blood cell
RCRI Revised Cardiac Risk Index
RCT Randomized controlled trial
RF Radiofrequency
rHuEPO Recombinant human erythropoietin
RR Relative risk
RV Right ventricular
SAPT Single antiplatelet therapy
SARS-CoV-2 Severe acute respiratory syndrome
coronavirus 2
SAVR Surgical aortic valve replacement
SCD Sudden cardiac death
SGLT-2 Sodium–glucose co-transporter-2
SORT Surgical Outcome Risk Tool
SPAP Systolic pulmonary artery pressure
STEMI ST-segment elevation myocardial
infarction
SVT Supraventricular tachycardia
TAVI Transcatheter aortic valve implantation
TEE Transoesophageal echocardiography
TEER Transcatheter edge-to-edge repair
TIA Transient ischaemic attack
TTE Transthoracic echocardiography
UFH Unfractionated heparin
ULN Upper limit of normal
VAD Ventricular assist device
VATS Video-assisted thoracic surgery
VEGFi Vascular endothelial grow factor
inhibitor
VF Ventricular fibrillation
VHD Valvular heart disease
VISION Vascular Events in Noncardiac Surgery
Patients Cohort Evaluation (trial)
VKA Vitamin K antagonist
VKORC1 Vitamin K epoxide reductase complex 1
VO2 Oxygen consumption
VT Ventricular tachycardia
VTE Venous thromboembolism
WHA World Health Assembly
WPW Wolff–Parkinson–White
1. Preamble
Guidelines summarize and evaluate available evidence, with the aim
of assisting health professionals in proposing the best management
strategies for an individual patient with a given condition.
Guidelines and their recommendations should facilitate decision-
making of health professionals in their daily practice. Guidelines,
however, are not a substitute for the patient’s relationship with their
practitioner. The final decisions concerning an individual patient must
be made by the responsible health professional(s), based on what
they consider to be the most appropriate in the circumstances.
These decisions are made in consultation with the patient and care-
giver as appropriate.
Guidelines are intended for use by health professionals. To en-
sure that all users have access to the most recent recommenda-
tions, the European Society of Cardiology (ESC) makes its
guidelines freely available. The ESC warns readers that the technical
language may be misinterpreted and declines any responsibility in
this respect.
Many guidelines have been issued in recent years by the ESC.
Because of their impact on clinical practice, quality criteria for the de-
velopment of guidelines have been established in order to make all
decisions transparent to the user. The recommendations for formu-
lating and issuing ESC Guidelines can be found on the ESC website
(https://www.escardio.org/Guidelines). The ESC Guidelines re-
present the official position of the ESC on a given topic and are regu-
larly updated.
In addition to the publication of Clinical Practice Guidelines, the
ESC carries out the EURObservational Research Programme of
international registries of cardiovascular diseases and interven-
tions, which are essential to assess diagnostic/therapeutic pro-
cesses, use of resources, and adherence to guidelines. These
registries aim to provide a better understanding of medical prac-
tice in Europe and around the world, and are based on high-quality
data collected during routine clinical practice. Furthermore, the
ESC develops sets of quality indicators (QIs)—which are tools
to evaluate the level of implementation of the guidelines and
may be used by the ESC, hospitals, healthcare providers, and
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professionals to measure clinical practice, and in educational pro-
grammes—alongside the key messages from the guidelines, to im-
prove quality of care and clinical outcomes.
The members of this Task Force were selected by the ESC to re-
present professionals involved with the medical care of patients with
this pathology. The selection procedure aimed to ensure that there is
a representative mix of members, predominantly from across the
whole of the ESC region and from relevant ESC Subspecialty
Communities. Consideration was given to diversity and inclusion,
notably with respect to gender and country of origin. A critical evalu-
ation of diagnostic and therapeutic procedures was performed, in-
cluding assessment of the risk–benefit ratio. The level of evidence
and the strength of the recommendation of particular management
options were weighed and scored according to pre-defined scales, as
outlined below. The Task Force followed the ESC voting procedures.
All recommendations subject to a vote achieved at least 75% among
voting members.
The experts of the writing and reviewing panels provided declar-
ation of interest forms for all relationships that might be perceived as
real or potential sources of conflicts of interest. Their declarations of
interest were reviewed according to the ESC declaration of interest
rules and can be found on the ESCwebsite (http://www.escardio.org/
Guidelines) and have been compiled in a report and simultaneously
published in a supplementary document to the guidelines. This pro-
cess ensures transparency and prevents potential biases in the devel-
opment and review processes. Any changes in declarations of
Table 1 Classes of recommendations
©
E S
C
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02
2
C
la
ss
es
of
re
co
m
m
en
da
ti
on
s
Class I Evidence and/or general agreement
that a given treatment or procedure is
Conflicting evidence and/or a divergence of opinion about the usefulness/ 
efficacy of the given treatment or procedure.
Is recommended or is indicated
Wording to useDefinition
Class III Evidence or general agreement that the
given treatment or procedure is not
may be harmful. 
useful/effective, and in some cases
Is not recommended
Class IIb
established by evidence/opinion.
May be considered
Class IIa W
favour of usefulness/efficacy.
Usefulness/efficacy is less well
eight of evidence/opinion is in Should be considered
Class II 
beneficial, useful, effective.
©
ES
C
20
22
Table 2 Levels of evidence
Level of
evidence A
Level of
evidence B
Level of
evidence C
Data derived from multiple randomized clinical trials
or meta-analyses.
Data derived from a single randomized clinical trial
or large non-randomized studies.
Consensus of opinion of the experts and/or small studies,
retrospective studies, registries.
©
ES
C
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02
2
©
ES
C
20
22
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interest that arose during the writing period were notified to the
ESC and updated. The Task Force received its entire financial sup-
port from the ESC without any involvement from the healthcare
industry.
The ESC CPG Committee supervises and coordinates the prepar-
ation of new guidelines. The Committee is also responsible for the
approval process of these guidelines. The ESC Guidelines undergo
extensive review by the CPG Committee and external experts, in-
cluding a mix of members from across the whole of the ESC region
and from relevant ESC Subspecialty Communities and National
Cardiac Societies. After appropriate revisions, the guidelines are
signed-off by all the experts involved in the Task Force. The finalized
document is signed-off by the CPG Committee for publication in the
European Heart Journal. The guidelines are developed after careful
consideration of the scientific and medical knowledge and the evi-
dence available at the time of their writing.
The task of developing the ESC Guidelines also includes creating
educational tools and implementating programmes for the recom-
mendations, including condensed pocket guidelines versions, sum-
mary slides, summary cards for non-specialists, and an electronic
version for digital applications (smartphones, etc.). These versions
are abridged and thus, for more detailed information, the user should
always access the full text version of the guidelines, which is
freely available via the ESC website and the European Heart Journal.
The National Cardiac Societies of the ESC are encouraged to
endorse, adopt, translate, and implement all ESC Guidelines.
Implementation programmes are needed because it has been shown
that the outcome of disease may be favourably influenced by the
thorough application of clinical recommendations.
Health professionals are encouraged to take the ESC Guidelines
fully into account when exercising their clinical judgment, and in de-
termining and implementing preventive, diagnostic, or therapeutic
medical strategies. However, the ESC Guidelines do not override,
in any way whatsoever, the individual responsibility of health profes-
sionals to make appropriate and accurate decisions in considering
each patient’s health condition and in consulting with that patient
or the patient’s caregiver where appropriate and/or necessary. It is
also the health professional’s responsibility to verify the rules and
regulations applicable in each country to drugs and devices at the
time of prescription and, where appropriate, to respect the ethical
rules of their profession.
Off-label use of medication may be presented in these guidelines
if a sufficient level of evidence shows that it can be considered med-
ically appropriate to a given condition and if patients could benefit
from the recommended therapy. However, the final decisions con-
cerning an individual patient must be made by the responsible health
professional, giving special consideration to:
(a) the specific situation of the patient. In this respect, it is specified
that, unless otherwise provided for by national regulations, off-
label use of medication should be limited to situations where it
is in the patient’s interest to do so, with regard to the quality,
safety, and efficacy of care, and only after the patient has been
informed and provided consent;
(b) and country-specific health regulations, indications by govern-
mental drug regulatory agencies, and the ethical rules to which
health professionals are subject, where applicable.
2. Introduction
2.1. What is new
Table 3 New concepts and sections in the current
guidelines
A new flowchart for general assessment of patients before NCS.
A new section on pre-operative assessment of patients with newly
detected murmurs, dyspnoea, oedema, or angina.
A new section on the patient perspective.
A new section on assessment of frailty.
A revised and expanded focus on use of biomarkers in NCS
A revised and expanded section on peri-operative management of
antiplatelet therapy.
A revised and expanded section on peri-operative management of
oral anticoagulants.
A new section on peri-operative thromboprophylaxis.
A dedicated section on patient blood management.
A new section on management of cardiovascular risk in patients with
cancer undergoing NCS.
A small section on NCS in patients with recent COVID-19.
A new section on diagnosis and management of post-operative
complications during NCS. ©
ES
C
20
22
COVID-19, coronavirus 2019; NCS, non-cardiac surgery
Table 4 What is new
©
ES
C
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22
Table 4A New recommendations
Recommendation Class
Clinical risk evaluation—Section 3
Patients scheduled for NCS
In all patients scheduled for NCS, an accurate history, and
clinical examination are recommended.
I
It is recommended to perform a pre-operative risk assessment,
ideally at the same time as the NCS is proposed.
I
If time allows, it is recommended to optimize
guideline-recommended treatment of CVD and CV risk factors
before NCS.
I
Endovascular or video-assisted procedures should be
considered for patients with high CV risk undergoing vascular
or pulmonary surgery.
IIa
Patients aged,65 years without signs, symptoms, or history
of CVD
In patients with a family history of genetic cardiomyopathy, it is
recommended to perform an ECG and TTE before NCS,
regardless of age and symptoms.
I
In patients aged 45–65 years without signs, symptoms, or
history of CVD, ECG and biomarkers should be considered
before high-risk NCS.
IIa
Continued
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Pre-operative assessment in patients with a newly detected
murmur, chest pain, dyspnoea, or peripheral oedema
In patients with a newly detected murmur and symptoms or
signs of CVD, TTE is recommended before NCS.
I
In patients with a newly detected murmur suggesting clinically
significant pathology, TTE is recommended before high-risk
NCS.
I
In patients with a newly detected murmur, but without other
signs or symptoms of CVD, TTE should be considered before
moderate and high-risk NCS.
IIa
If a patient scheduled for elective NCS has chest pain or other
symptoms suggestive of undetected CAD, further diagnostic
work-up before NCS is recommended.
I
If a patient in need of acute NCS also has chest pain or other
symptoms suggestive of undetected CAD, a multidisciplinary
assessment approach is recommended to choose the
treatment with lowest total risk for the patient.
I
In patients with dyspnoea and/or peripheral oedema, an ECG
and an NT-proBNP/BNP test is indicated before NCS, unless
there is a certain non-cardiac explanation.
I
In patients with dyspnoea and/or peripheral oedema and
elevated NT-proBNP/BNP, TTE is recommended before NCS.
I
Patient information
It is recommended to give patients individualized instructions
for pre-operative and post-operative changes in medication, in
verbal and written formats with clear and concise directions.
I
It should be considered to set up a structured information list
(e.g. a checklist to help with common issues) for patients with
CVD or at high risk of CV complications scheduled for NCS.
IIa
Pre-operative assessment tools—Section 4
Frailty and functional capacity
In patients aged ≥70 years, being scheduled to undergo
intermediate- or high-risk NCS, frailty screening should be
considered using a validated screening tool.
IIa
Adjusting risk assessments according to self-reported ability to
climb two flights of stairs should be considered in patients
referred for intermediate- or high-risk NCS.
IIa
Transthoracic echocardiography
TTE is recommended in patients with poor functional capacity
and/or high NT-proBNP/BNP, or if murmurs are detected before
high-risk NCS, in order to undertake risk-reduction strategies.
I
TTE should be considered in patients with suspected newCVD
or unexplained signs or symptoms before high-risk NCS.
IIa
TTE may be considered in patients with poor functional
capacity, abnormal ECG, high NT-proBNP/BNP, or ≥1 clinical
risk factor before intermediate-risk NCS.
IIb
To avoid delaying surgery, a FOCUS exam performed by
trained specialists may be considered as an alternative to TTE
for pre-operative triage.
IIb
Stress imaging
Stress imaging should be considered before high-risk NCS in
asymptomatic patients with poor functional capacity, and
previous PCI or CABG.
IIa
Continued
Coronary angiography
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
General risk-reduction strategies—Section 5
Cardiovascular risk factors and lifestyle interventions
Smoking cessation.4 weeks before NCS is recommended to
reduce post-operative complications and mortality.
I
Control of CV risk factors—including blood pressure,
dyslipidaemia, and diabetes—is recommended before NCS.
I
Pharmacological treatment
For patients on diuretics to treat hypertension, transient
discontinuation of diuretics on the day of NCS should be
considered.
IIa
It should be considered to interrupt SGLT-2 inhibitor therapy
for at least 3 days before intermediate- or high-risk NCS.
IIa
Antiplatelets
For patients undergoing high bleeding risk surgery (e.g.
intracranial, spinal neurosurgery, or vitreoretinal eye surgery),
it is recommended to interrupt aspirin for at least 7 days
pre-operatively.
I
In high-risk patients with a recent PCI (e.g. STEMI patients or
high-risk NSTE-ACS patients), a DAPT duration of at least 3
months should be considered before time-sensitive NCS.
IIa
Anticoagulants
When an urgent surgical intervention is required, it is
recommended that NOAC therapy is immediately interrupted.
I
In non-minor bleeding risk procedures in patients using a
NOAC, it is recommended to use an interruption regimen
based on the NOAC compound, renal function, and bleeding
risk.
I
In minor bleeding risk surgery and other procedures where
bleeding can easily be controlled, it is recommended to
perform surgery without interruption of OAC therapy.
I
In patients using NOACs, it is recommended that minor
bleeding risk procedures are performed at trough levels
(typically 12–24 h after last intake).
I
LMWH is recommended, as an alternative to UFH, for bridging
in patients with MHVs and high surgical risk.
I
For patients with mechanical prosthetic heart valves
undergoing NCS, bridging with UFH or LMWH should be
considered if OAC interruption is needed and patients have: (i)
mechanical AVR and any thromboembolic risk factor; (ii)
old-generation mechanical AVR; or (iii) mechanical mitral or
tricuspid valve replacement.
IIa
Idarucizumab should be considered in patients on dabigatran and
requiring urgent surgical intervention with intermediate to high
bleeding risk.
IIa
For interventions with a very high risk of bleeding, such as spinal
or epidural anaesthesia, interruption of NOACs for up to five
half-lives and re-initiation after 24 h should be considered.
IIa
Continued
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When specific reversal agents are unavailable, PCC or activated
PCC should be considered for reversing NOAC effects.
IIa
If an urgent surgical intervention is required, specific
coagulation tests and assessment of NOAC plasma levels
should be considered to interpret routine coagulation tests and
waning of anticoagulant effect.
IIa
If bleeding risk with resumption of full-dose anticoagulation
outweighs the risk of thromboembolic events, postponing
therapeutic anticoagulation 48–72 h after the procedure may
be considered, using post-operative thromboprophylaxis until
resumption of full OAC dose is deemed safe.
IIb
Bridging of OAC therapy is not recommended in patients with
low/moderate thrombotic risk undergoing NCS.
III
Use of reduced-dose NOAC to attenuate the risk of
post-operative bleeding is not recommended.
III
Thromboprophylaxis
It is recommended that decisions about peri-operative
thromboprophylaxis in NCS are based on individual and
procedure-specific risk factors.
I
If thromboprophylaxis is deemed necessary, it is
recommended to choose the type and duration of
thromboprophylaxis (LMWH, NOAC, or fondaparinux)
according to type of NCS, duration of immobilization, and
patient-related factors.
I
In patients with a low bleeding risk, peri-operative
thromboprophylaxis should be considered for a duration of up
to 14 or 35 days, for total knee or hip arthroplasty, respectively.
IIa
NOACs in thromboprophylaxis dose may be considered as
alternative treatments to LMWH after total knee and hip
arthroplasty.
IIb
Patient blood management
It is recommended to measure haemoglobin pre-operatively in
patients scheduled for intermediate- to high-risk NCS.
I
It is recommended to treat anaemia in advance of NCS in order
to reduce the need for RBC transfusion during NCS.
I
In patients undergoing surgery with expected blood loss of
≥500 mL, use of washed cell salvage is recommended.
I
It is recommended to use point-of-care diagnostics for
guidance of blood component therapy, when available.
I
The use of an algorithm to diagnose and treat anaemic patients
before NCS should be considered.
IIa
In patients undergoing NCS and experiencing major bleeding,
administration of tranexamic acid should be immediately
considered.
IIa
Use of closed-loop arterial blood sampling systems should be
considered to avoid blood loss.
IIa
Application of meticulous haemostasis should be considered a
routine procedure.
IIa
A feedback/monitoring programme or clinical decision support
system should be considered to be assessed before blood
transfusion.
IIa
Before allogenic blood transfusion, it should be considered
to obtain an extensive consent about risks associated with
transfusion.
IIa
Continued
Specific diseases—Section 6
Coronary artery disease
Pre-operative evaluation of patients with an indication for PCI
by an expert team (surgeon and cardiologist) should be
considered before elective NCS.
IIa
Heart failure
In patients with HF undergoing NCS, it is recommended to
regularly assess volume status and signs of organ perfusion.
I
A multidisciplinary team including VAD specialists is
recommended for peri-operative management of patients with
HF receiving mechanical circulatory support.
I
Valvular heart disease
In patients with symptomatic severe AR or asymptomatic
severe AR and LVESD .50 mm or LVESDi (LVESD/BSA)
.25 mm/m2 (in patients with small body size) or resting LVEF
≤50%, valve surgery is recommended prior to elective
intermediate- or high-risk NCS.
I
In patients with moderate-to-severe rheumatic MS and
symptoms or SPAP .50 mmHg, valve intervention (PMC or
surgery) is recommended before elective intermediate- or
high-risk NCS.
I
In asymptomatic patients with severe AS who are scheduled
for elective high-risk NCS, AVR (SAVR or TAVI) should be
considered after Heart Team discussion.
IIa
In patients with symptomatic severe primary MR or
asymptomatic severe primary MR with LV dysfunction (LVESD
≥40 mm and/or LVEF ≤60%), valve intervention (surgical or
transcatheter) should be considered prior to intermediate- or
high-risk NCS, if time allows.
IIa
In patients with severe secondary MR who remain
symptomatic despite guideline-directed medical therapy
(including CRT if indicated), valve intervention (transcatheter
or surgical) should be considered before NCS, in eligible
patients with an acceptable procedural risk.
IIa
In patients with severe symptomatic AS in need of
time-sensitive NCS or in whom the TAVI and SAVR are
unfeasible, BAV may be considered before NCS as a bridge to
definitive aortic valve repair.
IIb
Arrhythmias
In AF patients with acute or worsening haemodynamic
instability undergoing NCS, emergency electrical cardioversion
is recommended.
I
In patients with symptomatic, monomorphic, sustained VT
associated with myocardial scar, recurring despite optimal
medical therapy, ablation of arrhythmia is recommended
before elective NCS.
I
It is recommended that all patients with CIEDs that are
reprogrammed before surgery have a re-check and necessary
reprogramming as soon as possible after the procedure.
I
If indications for pacing exist according to the 2021 ESC
Guidelines on cardiac pacing and cardiac resynchronization
therapy, NCS surgery should be deferred and implantation of a
permanent pacemaker should be considered.
IIa
Continued
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Ablation should be considered in symptomatic patients with
recurrent or persistent SVT, despite treatment, prior to
high-risk, non-urgent NCS.
IIa
In high-risk CIED patients (e.g. with ICD or being
pacing-dependant) undergoing NCS carrying a high probability
of electromagnetic interference (e.g. involving unipolar
electrosurgery above the umbilical area), CIED check-up and
necessary reprogramming immediately before the procedure
should be considered.
IIa
Adult congenital heart disease
In patients with ACHD, a consultation with an ACHD specialist
is recommended before intermediate- or high-risk surgery.
I
In patients with ACHD, it is recommended that intermediate-
and high-risk elective surgery is performed in a centre with
experience in the care of ACHD patients.
I
Pericardial diseases
In patients with acute pericarditis, deferring elective NCS until
complete resolution of the underlying process should be
considered.
IIa
Avoiding elective NCS procedures under general anaesthesia
until colchicine or the immunosuppressive treatment course
for pericardial disease is completed may be considered.
IIb
Pulmonary arterial hypertension
Inodilator drugs (dobutamine, milrinone, levosimendan),
which increase cardiac output and lower pulmonary vascular
resistance, should be considered peri-operatively according to
the haemodynamic status of the patient.
IIa
Peripheral artery disease and/or abdominal aortic aneurysm
Routine referral for cardiac work-up, coronary angiography, or
CPET prior to elective surgery for PAD or AAA is not
recommended.
III
Renal disease
In patients with known risk factors (age .65 years, BMI .30,
diabetes, hypertension, hyperlipidaemia, CV disease, or
smoking) undergoing intermediate- or high-risk NCS, it is
recommended to screen for pre-operative renal disease by
measuring serum creatinine and GFR.
I
In patients with renal disease requiring peri-operative
contrast-enhanced radiography, balanced hydration with i.v.
isotonic fluids, the use of a minimal volume of contrast media,
and the use of low-osmolar or iso-osmolar contrast media
should be considered.
IIa
If a cystatin C measurement assay is available, cystatin C
measurement should be considered in patients with impaired
eGFR (,45–59 mL/min/1.73 m2) to confirm kidney disease.
IIa
Obesity
It is recommended to assess cardiorespiratory fitness to
estimate peri-operative CV risk in obese patients, with
particular attention to those undergoing intermediate- and
high-risk NCS.
I
In patients at high risk of obesity hypoventilation syndrome,
additional specialist investigation before major elective NCS
should be considered.
IIa
Continued
Diabetes mellitus
A pre-operative assessment for concomitant cardiac
conditions is recommended in patients with diabetes with
suspected or known CAD, and those with autonomic
neuropathy, retinopathy, or renal disease and scheduled to
undergo intermediate- or high-risk NCS.
I
Peri-operative monitoring and anaesthesia—Section 7
It is recommended to avoid post-operative acute pain. I
Perioperative cardiovascular complications—Section 8
It is recommended to have high awareness of peri-operative
CV complications combined with surveillance for PMI in
patients undergoing intermediate- or high-risk NCS.
I
Systematic PMI work-up is recommended to identify the
underlying pathophysiology and to define therapy.
I
It is recommended to treat post-operative STEMI, NSTE-ACS,
acute HF, and tachyarrhythmias in accordance with guidelines
for the non-surgical setting, after interdisciplinary discussion
with the surgeon about bleeding risk.
I
In patients with post-operative PE of high or intermediate
clinical probability, initiation of anticoagulation is
recommended without delay, while diagnostic work-up is in
progress, if bleeding risk is low.
I
Post-operative oral anticoagulation for PE is recommended to
be administered for a period of at least 3 months.
I
In patients with a post-operative indication for OAC, NOACs
are generally recommended over VKA.
I
In patients with post-operative AF after NCS, long-term OAC
therapy should be considered in all patients at risk of stroke,
considering the anticipated net clinical benefit of OAC therapy,
and informed patient preferences.
IIa
In patients with MINS and at low risk of bleeding, treatment
with dabigatran 110 mg orally b.i.d. may be considered from
about 1 week after NCS.
IIb
Routine use of beta-blocker for the prevention of post-
operative AF in patients undergoing NCS is not recommended.
III
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AAA, abdominal aortic aneurysm; ACHD, adults with congenital heart disease; AF, atrial
fibrillation; AR, aortic valve regurgitation; AS, aortic valve stenosis; AVR, aortic valve
replacement; BAV, balloon aortic valvuloplasty; b.i.d., twice a day; BMI, body mass index;
BNP, B-type natriuretic peptide; BSA, body surface area; CABG, coronary artery bypass
graft; CAD, coronary artery disease; CCS, chronic coronary syndrome; CCTA, coronary
computed tomography angiography; CIED, cardiac implantable electronic device; CPET,
cardiopulmonary exercise testing; CRT, cardiac resynchronization therapy; CV,
cardiovascular; CVD, cardiovascular disease; DAPT, dual antiplatelet therapy; ECG,
electrocardiogram; eGFR, estimated glomerular filtration rate; ESC, European Society of
Cardiology; FOCUS, focused cardiac ultrasound; GFR, glomerular filtration rate; HF,
heart failure; i.v., intravenous; LMWH, low molecular weight heparin; LV, left ventricular;
LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter;
LVESDi, left ventricular end-systolic dimension index; MHV, mechanical heart valve;
MINS, myocardial injury following non-cardiac surgery; MR, mitral valve regurgitation; MS,
mitral valve stenosis; NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral
anticoagulant; NSTE-ACS, non-ST-segment elevation acute coronary syndrome;
NT-proBNP, N-terminal pro-B-type natriuretic peptide; OAC, oral anticoagulant; PAD,
peripheral artery disease; PCC, prothrombin complex concentrate; PCI, percutaneous
coronary intervention; PE, pulmonary embolism; PMC, percutaneous mitral
commissurotomy; PMI, peri-operative myocardial infarction/injury; RBC, red blood cell;
SAVR, surgical aortic valve replacement; SGLT-2, sodium–glucose co-transporter-2;
SPAP, systolic pulmonary artery pressure; STEMI, ST-segment elevation myocardial
infarction; SVT, supraventricular tachycardia; TAVI, transcatheter aortic valve
implantation; TTE, transthoracic echocardiography; UFH, unfractionated heparin; VAD,
ventricular assist device; VKA, vitamin K antagonist; VT, ventricular tachycardia.
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Table 4B Revised recommendations
Recommendations in 2014 version Class Recommendations in 2022 version Class
Preoperative assessment tools—Section 4
Electrocardiography and biomarkers
Pre-operative ECG is recommended for patients who have risk
factor(s) and are scheduled for intermediate- or high-risk surgery. I
In patients who have known CVD or CV risk factors (including age
≥65 years), or symptoms or signs suggestive of CVD it is
recommended to obtain a pre-operative 12-lead ECG before
intermediate- or high-risk NCS.
I
Assessment of cardiac troponins in high-risk patients, both before
and 48–72 h after major surgery, may be considered. IIb
In patients who have known CVD, CV risk factors (including age
≥65 years), or symptoms suggestive of CVD, it is recommended to
measure hs-cTn T or hs-cTn I before intermediate- and high-risk
NCS, and at 24 h and 48 h afterwards.
I
NT-proBNP and BNP measurements may be considered for
obtaining independent prognostic information for peri- operative
and late cardiac events in high-risk patients.
IIb
In patients who have known CVD, CV risk factors (including age
≥65 years), or symptoms suggestive of CVD, it should be
considered to measure BNP or NT-proBNP before intermediate-
and high-risk NCS.
IIa
Universal pre-operative routine biomarker sampling for risk
stratification and to prevent cardiac events is not recommended. III
In low-risk patients undergoing low- and intermediate-risk NCS, it
is not recommended to routinely obtain pre-operative ECG,
hs-cTn T/I, or BNP/NT-proBNP concentrations.
III
Coronary angiography
Pre-operative ICA is not recommended in cardiac-stable patients
undergoing low-risk surgery.
III Routine pre-operative ICA is not recommended in stable CCS
patients undergoing low- or intermediate-risk NCS.
III
General risk-reduction strategies—Section 5
Pharmacological treatment
Transient discontinuation of ACEIs or ARBs before NCS in
hypertensive patients should be considered.
IIa In patients without HF, withholding RAAS inhibitors on the day of
NCS should be considered to prevent peri-operative hypotension.
IIa
Antiplatelets
Consideration should be given to performing non-urgent NCS in
patients who have had recent DES implantation no sooner than 12
months following the intervention. This delay may be reduced to 6
months for the new-generation DES.
IIa
It is recommended to delay elective NCS until 6 months after
elective PCI and 12 months after an ACS. I
It is recommended that aspirin be continued for 4 weeks after BMS
implantation and for 3–12 months after DES implantation, unless
the risk of life-threatening surgical bleeding on aspirin is
unacceptably high.
I
After elective PCI, it is recommended to delay time-sensitive NCS
until a minimum of 1 month of DAPT treatment has been given. I
Continuation of aspirin, in patients previously thus treated, may be
considered in the peri-operative period, and should be based on an
individual decision that depends on the peri- operative bleeding
risk, weighed against the risk of thrombotic complications.
IIb
In patients with a previous PCI, it is recommended to continue
aspirin peri-operatively if the bleeding risk allows. I
Discontinuation of aspirin therapy, in patients previously treated
with it, should be considered in those in whom haemostasis is
anticipated to be difficult to control during surgery.
IIa
In patients without a history of PCI, interruption of aspirin at least 3
days before NCS may be considered if the bleeding risk outweighs
the ischaemic risk, to reduce the risk of bleeding.
IIb
In patients treated with P2Y12 inhibitors, who need to undergo
surgery, postponing surgery for at least 5 days after cessation of
ticagrelor and clopidogrel—and for 7 days in the case of prasugrel
—if clinically feasible, should be considered unless the patient is at
high risk of an ischaemic event.
IIa
If interruption of P2Y12 inhibitor is indicated, it is recommended to
withhold ticagrelor for 3–5 days, clopidogrel for 5 days, and
prasugrel for 7 days prior to NCS. I
Specific diseases—Section 6
Coronary artery disease
If PCI is indicated before semi-urgent surgery, the use of
new-generation DES, BMS or even balloon angioplasty is
recommended.
I
If PCI is indicated before NCS, the use of new-generation DES is
recommended over BMS and balloon angioplasty. I
Continued
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2.2. The magnitude of the problem
The annual volume of major surgery worldwide is estimated to be
more than 300 million patients (about 5% of the world population),
which is a 34% increase from 2004 to 2012.1,2 Nearly 74% of these
operations are performed in countries spending substantial amounts
on health care. When applied to European Union countries, which
had an overall population of 448 million in 2020 (27 countries),
this figure translates into a crude estimate of nearly 22 million major
procedures annually.2
Nearly 85% of major operations are non-cardiac surgical proce-
dures.3 In a recent report from the USA National Inpatient Sample
database, nearly half of adults aged≥45 years undergoing major non-
Arrhythmias
Patients with ICDs, whose devices have been pre-operatively
deactivated, should be on continuous cardiac monitor throughout
the period of deactivation. External defibrillation equipment
should be readily available. I
It is recommended that patients with temporarily deactivated ICDs
have continuous ECG monitoring, and during the peri-operative
period are accompanied by personnel skilled in early detection and
treatment of arrhythmias. In high-risk patients (e.g.
pacemaker-dependant or ICD patients), or if access to the torso
will be difficult during the procedure, it is recommended to place
transcutaneous pacing/defibrillation pads prior to NCS.
I
Hypertension
Large peri-operative fluctuations in blood pressure in hypertensive
patients should be avoided. IIa
In patients with chronic hypertension undergoing elective NCS, it is
recommended to avoid large peri-operative fluctuations in blood
pressure, particularly hypotension, during the peri-operative
period.
I
Clinicians may consider not deferring NCS in patients with grade 1
or 2 hypertension (systolic blood pressure ,180 mmHg; diastolic
blood pressure ,110 mmHg).
IIb
It is not recommended to defer NCS in patients with stage 1 or 2
hypertension. III
Peripheral artery disease
Patients with PAD should be clinically assessed for ischaemic heart
disease and, if more than two clinical risk factors are present, they
should be considered for pre-operative stress or imaging testing. IIa
In patients with poor functional capacity or with significant risk
factors or symptoms (such as moderate-to-severe angina pectoris,
decompensated HF, valvular disease and significant arrhythmia),
referral for cardiac work-up and optimization is recommended
prior to elective surgery for PAD or AAA.
I
Diabetes mellitus
In patients at high surgical risk, clinicians should consider screening
for elevated HbA1c before major surgery and improving
pre-operative glucose control. IIa
In patients with diabetes or disturbed glucose metabolism, a
pre-operative HbA1c test is recommended, if this measurement
has not been performed in the previous 3 months. In case of
HbA1c ≥8.5% (≥69 mmol/mol), elective NCS should be
postponed, if safe and practical.
I
Peri-operative monitoring and anaesthesia—Section 7
Patients with high cardiac and surgical risk should be considered for
goal-directed therapy. IIa
In order to preserve optimal CV stability, it is recommended to
apply goal-directed haemodynamic therapy in patients undergoing
high-risk NCS.
I
Avoiding arterial hypotension (mean arterial pressure
,60 mmHg) for prolonged cumulative periods (.30 min) may be
considered.
IIb
In order to minimize the risk of post-operative organ dysfunction,
it is recommended to avoid an intra-operative mean arterial
pressure decrease of .20% from baseline values or ,60–
70 mmHg for ≥10 min.
I
Avoiding non-steroidal anti- inflammatory drugs (especially
cyclo-oxygenase-2 inhibitors) as the first-line analgesics in patients
with IHD or stroke may be considered.
IIb
Non-aspirin NSAIDs are not recommended as first-line analgesics
in patients with established or high risk of CVD. III
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AAA, abdominal aortic aneurysm; ACEI, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; BNP, B-type natriuretic peptide; BMS, bare metal stent; CCS,
chronic coronary syndrome; CV, cardiovascular; CVD, cardiovascular disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; ECG, electrocardiogram; HbA1c, glycated
haemoglobin A1c; HF, heart failure; hs-cTn, high-sensitivity cardiac troponin; ICA, invasive coronary angiography; ICD, implantable cardioverter–defibrillator; IHD, ischaemic heart
disease; NCS, non-cardiac surgery; NSAID, non-steroidal anti-inflammatory drug; NT-proBNP, N-terminal pro-B-type natriuretic peptide; PAD, peripheral artery disease; PCI,
percutaneous coronary intervention; RAAS, renin−angiotensin−aldosterone system.
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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 preva-
lence rates show a substantial increase compared with the equivalent
rates in 2008–09.4 In a large registry including 37 915 consecutive pa-
tients 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 complica-
tions. 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 compli-
cations can particularly occur in patients with documented or asymp-
tomatic 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 mis-
match on the background of coronary artery stenosis that may be-
come 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 sur-
gery, and the haemodynamic distress resulting from fluid shifts and
anaesthesia; and (iii) surgery-associated bleeding risk requiring inter-
ruption of antiplatelet therapies, which might lead to stent throm-
bosis 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, peri-
operative 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%), depend-
ing on safety precautions.7 In a recent prospective study of 2265
high-risk patients undergoing NCS in Switzerland, one out of five de-
veloped major adverse events within 365 days.8When applied to the
population in European Union countries, these figures translate into
at least 660 000 major cardiac or cerebrovascular complications oc-
curring annually due to NCS procedures.
The 2022 ESC Guidelines on cardiovascular assessment and man-
agement 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 ma-
jor impact on peri-operative patientmanagement. Patients undergoing
NCS are older than the rest of the population. Furthermore, it is es-
timated 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
by60%. 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 to-
wards 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 cardio-
vascular 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 in-
crease in the risk of complications; greater risks are associatedwith ur-
gency and significant CV, pulmonary, and renal disease.
2.4. Purpose
Asmany 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 sec-
tions 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 post-
operative care of patients undergoing NCS. The objective is to en-
dorse 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 an-
aesthetic techniques, or withholding medical therapy, in order to op-
timize 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 deci-
sions. 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 as-
sessment 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 re-
commendations made, but with different levels of evidence.
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These guidelines have the potential to improve peri- and post-
operative outcomes and highlight the existence of a clear opportunity
for improving the quality of care. Following the publication of these
updated guidelines onNCS, their effects on outcomes should bemon-
itored. The objective evaluations of the quality of the assessments and
the outcomes are described in quality indicators (Section 13).
2.5. The outcomes we want to prevent
The recommendations in these guidelines are intended to prevent
peri-operative CV morbidity and mortality, for example: peri-
operative myocardial infarction/injury (PMI), stent thrombosis, acute
heart failure (HF), haemodynamically relevant arrhythmias, pulmon-
ary embolism (PE), ischaemic stroke, and death. It is also important
to prevent bleeding complications, especially associated with antith-
rombotic treatment, since bleeding is associated with an increased
risk of MI and death.6,11–13
3. Clinical risk evaluation
Cardiovascular morbidity and mortality in patients undergoing NCS
are determined by two main factors: patient-related risk and type of
surgery or procedure, including the circumstances under which it
takes place (experience of institution, elective vs. emergency proced-
ure).14 The risk may be reduced by an adequate pre-operative evalu-
ation and proper selection of type and timing of the surgical
procedure (Figure 1).
3.1. Surgery-related risk
The surgery-related risk is determined by the type and duration
of the surgery, and the urgency of the procedure or intervention.
The type of anaesthesia and anaesthetic drugs may also influence
the risk of complications in patients at intermediate to high cardiac
risk undergoing NCS (see Section 7).15 The surgical risk estimate is
a broad approximation of 30 day risk of CV death, MI, and stroke,
which only takes into account the specific surgical intervention with-
out considering the patient’s comorbidities (Table 5).10,16
Any surgical procedure may increase the level of cortisol and ca-
techolamines as stress responses due to tissue injury and inflamma-
tion, and neuro–endocrine and sympathovagal imbalance. Changes in
body core temperature, blood loss, and fluid shifts may cause a rise in
vascular resistance as well as hypotension,17 leading to imbalance be-
tween myocardial oxygen demand and delivery. Bleeding, transfusion
of blood products, tissue injury, and inflammatory response may af-
fect the coagulation system, inducing a prothrombotic state.
Consider
postponing
or avoiding  
High
attention
Increased
attention
Increased
attention
Attention
Increased
attention
Attention
High riskModerate riskLow risk
CV risk reduction
(Patient)
Surgery- 
related risk
Patient-related riskRisk reduction 
(Surgery)
High risk
Moderate risk
Low risk
High
attention
Attention
Figure 1 Total risk is an interaction of patient-related and surgery-related risk. Ideally, the total risk should be as close as possible to the lower left
corner, by choosing surgery/procedure/anaesthesia/institution with the lowest possible risk along with efforts to mitigate the patient’s CV risk.
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3.1.1. Timing of surgery
In general, acute procedures carry a higher risk of complications than
elective procedures. Uniform timing definitions are unfeasible, as the
time spans may vary between diseases. These guidelines use the tim-
ing definitions below.
Immediate: surgery/intervention should be performed without
any delay to save life or organ function.
Urgent: surgery/intervention should be performed without un-
necessary delay to save life, limb, or organ function.
Time-sensitive: surgery/intervention should be performed as
soon as possible as there is a time-dependent risk of losing limb or
organ function, or increased risk of complications. Cancer surgery
is typically time-sensitive, as is carotid surgery to prevent stroke in
a symptomatic case. The time window for time-sensitive surgery
will vary depending on the underlying disease.
Elective: surgery/intervention can be performed electively (not
further defined) without significant risk of losing limb, or organ func-
tion, or increased risks of complications.
Many factors affect outcomes when comparing acute or time-
sensitive vs. elective surgery: the general condition of the patient
vs. the stage of the acute illness, and how far it has progressed.
The best interests of the patient should be considered before
deciding on treatment, informed consent to management should
be obtained, if at all possible, and decisions should be clearly
recorded.24
The degree of urgency should also be considered (i.e. does
the procedure need to be performed outside working hours
or can it wait until the next day?). In general, competences
and supportive functions are not always present in the evenings
or during the night; thus, an overall evaluation of what best
serves the patient is necessary. The optimal timing of NCS
should be discussed within the multidisciplinary team, including
an anaesthesiologist, in order to achieve optimized anaesthesia
for each patient (see Section 7).
3.2. Type of surgical approach
New surgical techniques have been introduced to replace open sur-
gery and to reduce the overall risk for the patient.
3.2.1. Laparoscopy
Laparoscopic procedures, compared with open surgical procedures,
have the advantage of causing less tissue trauma and intestinal paralysis,
resulting in less incisional pain, better post-operative pulmonary func-
tion, significantly fewer wall complications, and diminished post-
operative fluid shifts related to bowel paralysis.25 However, the pneu-
moperitoneum required for these procedures results in elevated
intra-abdominal pressure and a reduction in venous return. Typical
physiological sequelae are secondary to increased intra-abdominal
pressure and absorption of the gaseous medium used for insufflation.
While healthy individuals on controlled ventilation typically toler-
ate pneumoperitoneum, patients with CVD, some types of adults
with congenital heart disease (ACHD), and obese patients may ex-
perience adverse consequences.26 Pneumoperitoneum and
Trendelenburg position result in increased mean arterial pressure,
central venous pressure, mean pulmonary artery pressure, pulmon-
ary capillary wedge pressure, and systemic vascular resistance im-
pairing cardiac function.27,28 Therefore, compared with open
surgery, the CV risk in patients with CVD is not necessarily reduced
in patients undergoing laparoscopy, and both should be evaluated in
the same way. This is especially true in patients undergoing inter-
ventions for morbid obesity, but also in other types of surgery, con-
sidering the risk of conversion to an open procedure.29,30 Superior
short-term outcomes of laparoscopic vs. open procedures have
been reported, depending on type of surgery, operator experience,
Table 5 Surgical risk estimate according to type of surgery or intervention
Low surgical risk (,1%) Intermediate surgical risk (1–5%) High surgical risk (.5%)
• Breast
• Dental
• Endocrine: thyroid
• Eye
• Gynaecological: minor
• Orthopaedic minor (meniscectomy)
• Reconstructive
• Superficial surgery
• Urological minor: (transurethral resection
of the prostate)
• VATS minor lung resection
• Carotid asymptomatic (CEA or CAS)
• Carotid symptomatic (CEA)
• Endovascular aortic aneurysm repair
• Head or neck surgery
• Intraperitoneal: splenectomy, hiatal hernia
repair, cholecystectomy
• Intrathoracic: non-major
• Neurological or orthopaedic: major (hip and
spine surgery)
• Peripheral arterial angioplasty
• Renal transplants
• Urological or gynaecological: major
• Adrenal resection
• Aortic and major vascular surgery
• Carotid symptomatic (CAS)
• Duodenal-pancreatic surgery
• Liver resection, bile duct surgery
• Oesophagectomy
• Open lower limb revascularization for acute limb
ischaemia or amputation
• Pneumonectomy (VATS or open surgery)
• Pulmonary or liver transplant
• Repair of perforated bowel
• Total cystectomy ©
ES
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22
CAS, carotid artery stenting; CEA, carotid endarterectomy; CV, cardiovascular; MI, myocardial infarction; VATS, video-assisted thoracic surgery.
Surgical risk estimate is a broad approximation of 30 day risk of CV death, MI, and stroke that takes into account only the specific surgical intervention, without considering the patient’s
comorbidities.
Adapted from data in Glance et al., Muller et al., Bendixen et al., and Falcoz et al.18–23
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and hospital volume; however, few studies provide direct measures
of cardiac complications.31–33 The benefit of laparoscopic proce-
dures is probably greater in elderly patients, with reduced length
of hospital stay, intra-operative blood loss, incidence of post-
operative pneumonia, time to return of normal bowel function, in-
cidence of post-operative cardiac complications, and wound
infections.34
3.2.1.1. Vascular and endovascular procedures
Endovascular abdominal aortic aneurysm repair (EVAR) is a pro-
cedure using femoral artery access only, and is therefore asso-
ciated with lower operative mortality and morbidity than open
repair. It minimizes the surgical risk in simultaneous surgery for
the treatment of abdominal aortic aneurysm (AAA) and a non-
cardiac disorder, and shortens the time delay from the treatment
of AAA and the non-cardiac disorder in patients undergoing two-
phase surgery.35–37 The early gain in mortality from EVAR proce-
dures is lost after 3–4 years, compared with open surgical treat-
ment, due to general morbidity (especially CV mortality) of
AAA patients.
Various vascular and non-vascular NCS procedures bear different
operative risks. While aortic and infra-inguinal vascular surgical
procedures are both regarded as high-risk procedures, their risk
can be modified by adequate peri-operative measures.38 For
patients undergoing treatment of femoropopliteal artery disease,
an endovascular-first approach may be advisable in case of additional
significant comorbidity. A meta-analysis of studies comparing open
surgery with PCI for the treatment of femoropopliteal arterial dis-
ease showed that femoral bypass surgery was associated with higher
morbidity (odds ratio [OR] 2.93; 95% confidence interval [CI], 1.34–
6.41) but similar mortality at 30 days compared with endovascular
treatment.39
3.2.1.2. Video-assisted non-cardiac surgery
Video-assisted thoracic surgery (VATS) is supported by a trial
showing fewer peri-operative complications and a better quality
of life in the first year following surgery for stage 1 lung cancer com-
pared with anterolateral thoracotomy.20 Also, a large propensity
matched study conducted by the European Society of Thoracic
Surgeons (ESTS) showed fewer post-operative complications fol-
lowing VATS compared with open thoracotomy.21 Overall, the
benefits seem greatest in patients with reduced functional lung
capacity.
3.3. Patient-related risk
3.3.1. Initial assessment
Patient-related risk is determined by patient’s age, the presence or
absence of CV risk factors (e.g. smoking, hypertension, diabetes, dys-
lipidaemia, family disposition)40 or established CV disease, and
comorbidities.41
Identification of patients at risk of CV complications is of para-
mount importance to choice of therapy when non-surgical options
are available, or when the type of surgery or anaesthesia impacts
the risk of complications. When emergency surgery is needed, the
evaluation must necessarily be limited; however, most clinical cir-
cumstances allow a systematic approach.
As an initial assessment, it is recommended that all patients sched-
uled for NCS are evaluated by accurate history and physical examin-
ation, with special emphasis on CV risk factors, established CV
disease, and comorbidities.40 It is also recommended to measure
standard laboratory tests (e.g. haemoglobin and renal function) in all
patients undergoing intermediate- to high-risk surgery. Based on this
information, further assessment of patient-related risk can proceed
depending on the surgery-related risk, as shown in Figure 2. It is recom-
mended to perform an electrocardiogram (ECG), assess the functional
capacity, and/or measure biomarkers (cardiac troponins and/or
N-terminal pro-B-type natriuretic peptide [NT-proBNP]/B-type natri-
uretic peptide [BNP]) depending on the patient-related and
surgery-related risk (Figure 2). Detailed information on available tools
for risk assessment, their prognostic ability, and indications to perform
them is given in Section 4. More details on pre-operative management
of patients with specific CV diseases are given in Section 6.
3.3.1.1. Patients aged ,65 years without a history of
cardiovascular disease or cardiovascular risk factors
Patients aged,65 years without signs, symptoms, or history of CVD
or CV risk factors are considered to be of low risk, and can proceed
to low- and moderate-risk surgery without additional pre-operative
risk assessment.41 Before high-risk surgery, ECG and biomarkers
should be considered (see Sections 4.3 and 4.4).42
Patients without signs or symptoms of CVD, but with a family his-
tory of genetic cardiomyopathy (i.e. dilatated, hypertrophic, arrhyth-
mic, or restrictive cardiomyopathy, or LV non-compaction) should
be evaluated with an ECG and an echocardiographic examination
to rule out the presence of the disease, irrespective of the age.43
No specific data are available in the literature regarding risk of family
members without the phenotype; however, they are at risk of devel-
oping the disease, which may be subclinical at the time of the NCS.43
3.3.1.2. Patients aged ≥65 years or with cardiovascular risk
factors
Patients who are aged ≥65 years and patients with risk factors for
CVD—such as hypertension, dyslipidaemia, or smoking—have an
increased risk of having undetected CVD. The SCORE2 risk-
prediction tool can be used to estimate their 10 year CVD risk
outside the setting of NCS.40 Patients who are aged ≥65 years
and patients with risk factors for CVD also have an increased
risk of peri-operative complications during NCS.41,44 These
patients need additional assessment before intermediate- and
high-risk surgery (Figure 2) and optimal treatment of risk factors.
Recommendation Table 1 — Recommendations for
selection of surgical approach and impact on risk
Recommendations Classa Levelb
Endovascular or video-assisted procedures should
be considered for patients with high CV risk
undergoing vascular or pulmonary surgery.21,35–39
IIa B
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CV, cardiovascular.
aClass of recommendation.
bLevel of evidence.
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This is also the case for patients with other diseases known to be
associated with a high risk of concomitant undetected or known
CVD (Sections 6.8 and 6.11–6.14).
3.3.1.3. Patients with established cardiovascular disease
The surgical procedure has the potential to aggravate the disease
and increase morbidity and mortality in patients with established
CVD. This may be preventable by implementing appropriate CV
risk stratification prior to NCS and individually tailoring
peri-operative therapy to reduce the risk.45 If time allows, it is
also recommended to optimize guideline-recommended treat-
ment of the disease before NCS. See Section 6 for a detailed
discussion of risk assessment and management of patients with
known CVD.
N
Management of patients before non-cardiac surgery (NCS)
Accurate history and clinical examination, including standard lab tests (Class I)
Advise on stopping smoking, optimize guideline-recommended medical therapy (Class I)
<65 years without any
CVD/CV risk factorsa
Patients with established CVD
Low-risk NCS
≥65 years
or with CV risk factorsa
Emergent or urgent NCS
N
Time-sensitive NCS
Elective NCS
Cardiac testing not feasiblee
Multidisciplinary decision of 
individualized cardiac testing.
If time, manage as elective NCS
Y
Y
None (see section 6)
Intermediate-risk NCS
ECG, biomarkersb (Class I)
Functional capacityc (Class IIa)
(see section 6)
High-risk NCS
ECG, biomarkersb (Class I)
Functional capacityc (Class IIa)
+ cardiology consultationd
(see section 6)
Multidisciplinary decision
None
Intermediate-risk NCS
ECG, biomarkersb (Class I)
Functional capacityc (Class IIa)
High-risk NCS
ECG, biomarkersb (Class I)
Functional capacityc (Class IIa)
None
Intermediate-risk NCS
None
High-risk NCS
In patients >45 year, consider:
ECG, biomarkersb
(Class IIa)
Low-risk NCSLow-risk NCS
Figure 2 Pre-operative assessment before non-cardiac surgery. CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram; N, no; NCS,
non-cardiac surgery. Y, yes; aCV risk factors: hypertension, smoking, dyslipidaemia, diabetes, family history of CVD. bBiomarkers: hs-cTn T/I (Class I) and/
or BNP/NT-proBNP (Class IIa). If pathological, consult a cardiologist. cFunctional capacity based on Duke Activity Status Index (DASI) or the ability to
climb two flights of stairs. dFor diagnostic and therapeutic efforts to be considered, see Section 6. eClose follow-up after intervention and subsequent
management of heart disease are advised.
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3.3.2. Patients withmurmurs, chest pain, dyspnoea,
or peripheral oedema
Patients without known CVD and scheduled for elective or acute
NCS are often referred to a cardiologist because of symptoms or
signs that may be caused by CVD. Murmurs, chest pain, dyspnoea,
and oedema may suggest severe CVD, but may also be caused by
non-cardiac disease. Thus, the medical history, family history, and
risk factors have to be obtained and considered. The patient’s phys-
ical capacity should be assessed. The need for further evaluation of
the patient should be decided according to the risk of the planned
procedure or surgery.
3.3.2.1. Murmurs
In a patient with a heart murmur, but without any symptoms of CVD,
the value of performing an echocardiogram is not well-established
and consensus is missing.54–56 However, if a heart murmur suggesting
clinically significant pathology is present before high-risk NCS, it is re-
commended to perform an echocardiogram, even in patients with-
out any symptoms of CVD. Old age or increased NT-proBNP may
increase the pre-test probability of haemodynamically significant
but asymptomatic valvular disease. If the patient with the murmur
also has symptoms of CVD, an echocardiogram is indicated before
all NCS. The pre-operative setting is challenging, as the need for
NCS and the risk of CVD have to be considered as independent fac-
tors. Thus, an echocardiogram may be useful in risk stratification for
some patients, but whether it would improve outcome is uncertain.
It is important to bear in mind that the time delay when performing
additional but unnecessary examinations may worsen the patient’s
prognosis.57 It has also been discussed that a focused cardiac ultra-
sound (FOCUS) could replace auscultation in general in the pre-
operative evaluation of patients.58 While cardiac auscultation has se-
vere limitations,59,60 the value of performing a FOCUS as a standard
pre-operative evaluation remains uncertain. Cardiac auscultation
should not be replaced by FOCUS.
3.3.2.2. Chest pain
Patients scheduled for NCS may also present with previously unrec-
ognized symptoms suggestive of CAD. The disease leading to the
need for NCS may aggravate a subclinical CAD, or the patient may
have a concomitant undetected CAD. In an elective setting, if the
symptoms are suggestive of CAD, the guidelines for CAD patients
in the non-surgical setting should be followed (see Sections 4.5.3
and 6.1.2). If immediate, urgent, or time-sensitive NCS is needed,
the time for and access to adequate diagnostic tools may be limited.
However, ECG and troponins can be used to detect or exclude ACS
(see Sections 4.3 and 4.4).
3.3.2.3. Dyspnoea
Dyspnoea is a symptom of a wide range of diseases and conditions. In
a large series of patients, self-reported dyspnoea identified a sub-
group of otherwise asymptomatic patients at increased risk of death
fromCVD and any cause.61 In the diagnostic work-up to find the rea-
son for dyspnoea, spirometry, D-dimer, NT-proBNP/BNP, arterial
blood gases, and transthoracic echocardiography (TTE) have diag-
nostic utility61 but limited specificity. If NT-proBNP/BNP is elevated,
an echocardiogram should be performed. If NT-proBNP/BNP is not
elevated, other reasons for dyspnoea should be explored.
3.3.2.4. Peripheral oedema
Increased hydrostatic pressure leading to oedema is a feature of a
wide range of CV diseases, but an upright position is also a common
cause of oedema. There is a spectrum of other diseases that can re-
sult in peripheral oedema not listed here.
Recommendation Table 2 — Recommendations for
all patients scheduled for non-cardiac surgery
Recommendations Classa Levelb
In all patients scheduled for NCS, an accurate
history and clinical examination are
recommended.
I C
It is recommended to perform a pre-operative
risk assessment, ideally at the same time as the
NCS is proposed.46–53
I B
If time allows, it is recommended to optimize
guideline-recommended treatment of CVD and
CV risk factors before NCS.
I C
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CV, cardiovascular; CVD, cardiovascular disease; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
Recommendation Table 3 — Recommendations for
patients aged ,65 years without signs, symptoms, or
history of cardiovascular disease
Recommendations Classa Levelb
In patients with a family history of genetic
cardiomyopathy, it is recommended to perform
an ECG and TTE before NCS, regardless of age
and symptoms.
I C
In patients aged 45–65 years without signs,
symptoms, or history of CVD, ECG and
biomarkers should be considered before high-risk
NCS.
IIa C
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ECG, electrocardiogram; NCS, non-cardiac surgery; TTE, transthoracic
echocardiography.
aClass of recommendation.
bLevel of evidence.
Recommendation Table 4 — Recommendations for
pre-operative assessment in patients with previously
unknown murmur, angina, dyspnoea, or peripheral
oedema
Recommendations Classa Levelb
Newly detected murmur
In patients with a newly detected murmur and
symptoms or signs of CVD, TTE is recommended
before NCS.
I C
Continued
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3.4. Timing of adequate risk evaluation
Pre-operative CV assessment should be performed prior to surgery,
ideally at the time when the decision for NCS has been made.
Accurate estimates of the risks and benefits of surgery is a prerequisite
for informed decision-making by both physicians and patients about the
appropriateness of surgery. These estimates should also help in guiding
surgical (endovascular/endoscopic vs. open approach) and monitoring
(intermediate care, screening for CV complications) approaches, and
help to detect an unexpectedly high CV risk.47 Therefore, the prognos-
tic value of pre-operative CV risk assessment is much higher in elective
vs. immediate or urgent surgery. Explicit communication of peri-
operative CV risk, on the basis of the expected event rates,47 and risk
communication tools such as the A to Z Inventory of Decision Aids
(https://decisionaid.ohri.ca/AZinvent.php) are recommended.
3.5. Avoidance or allowance for surgery
in the individual patient
In the clinical setting it can be difficult to decide whether CVD repre-
sents a contraindication to NCS. In general, the risk for the patient if
not operated on must be considerably higher than the risk of the
treatment. Ideally, an unstable cardiac patient should be stabilized be-
fore NCS, but waiting can be detrimental for acute surgical disease.
No definite list can bemade for which cardiac disease is a clear contra-
indication to NCS, but in patients with severe HF (New York Heart
Association [NYHA] class IV), cardiogenic shock, severe pulmonary
hypertension, or patients with severe frailty (see Section 4.1.2 for
frailty assessment), high-risk NCS should probably be avoided. Life ex-
pectancy and quality of life should also be taken into consideration.
However, the decision should be made after discussions between
the surgeon, anaesthesiologist, cardiologist, and also a geriatrician
for elderly patients, along with the patient and relatives.
3.6. The patient perspective
Patients with established CVDmay face concerns about their under-
lying disease and current CV medication, co-ordination between the
surgical team and their cardiologist (examples provided in Figure 3),
and the potential excessive risk compared with the expected out-
come of the surgery. Time should be allowed to address concerns
and to provide evidence-based information on the risk–benefit
trade-offs and the surgical treatment options (including non-surgical
or ‘do nothing’ alternatives) to ensure informed consent, and to al-
low patients to engage in shared decision-making with the aim of sup-
porting the best decision. The team needs to understand the
patient’s concerns and expectations about the treatment and short-
and long-term goals, as the risk-benefits of the intervention may not
be aligned with patient preferences and wishes. Communicating in
plain language (oral and written) and targeting communication to
fit the individual level of health literacy is pivotal. Several studies
have indicated a relatively high prevalence of limited health literacy
in patients with CVD (e.g. with HF),62 and limited health literacy is
associated with adverse outcomes.63 An example of a patient infor-
mation sheet to be used in the communication with patients is given
in the Supplementary data, Table S1.
Recent systematic reviews and meta-analyses have focused on
shared decision-making in the field of surgery across disease
areas.64–67 In general, shared decision-making positively impacts de-
cisional conflicts, knowledge gained, satisfaction, and decisional anx-
iety (although cultural variations may exist).67 In the breast cancer/
endocrine and urology specialties, decision-making and communica-
tion aids appear to be effective methods for supporting patients’ in-
volvement in decision-making when undergoing elective surgery.
Moreover, educational information, provided through interactive
multimedia, computer, or on DVD, used prior to the surgical con-
sultation could enhance the decision-making process in addition to
face-to-face communication.66
In Europe, the prevalence of pre-operative anxiety among patients
undergoing surgical procedures varies from 27–80%.68 Although a
certain level of anxiety in patients must be expected, peri-operative
anxiety is associated with worse surgical outcomes and longer recov-
ery,69–72 which highlights the importance of pre-surgical assessment
and, in some patients, treatment of anxiety. Factors associated with
pre-operative anxiety are complex and include, among others, age,
sex, educational level, type of surgery, and fear of post-operative
complications or the outcome.68 Psychological reactions in patients
undergoing high- or medium–high-risk procedures and/or patients
with previous negative experiences of NCS may warrant particular
attention. Concerns and fears expressed by patients and relatives
should be taken seriously. A number of reviews and meta-analyses
have summarized the effects of interventions on surgical outcomes in
abdominal, cardiac, and orthopaedic surgery, which may also be applic-
able to patients with CV conditions in these settings.73–75
In patients with a newly detected murmur
suggesting clinically significant pathology, TTE is
recommended before high-risk NCS.
I C
In patients with a newly detected murmur, but
without other signs or symptoms of CVD, TTE
should be considered before moderate-risk NCS.
IIa C
Previously unknown angina
If a patient scheduled for elective NCS has chest
pain or other symptoms suggestive of undetected
CAD, further diagnostic work-up before NCS is
recommended.
I C
If a patient in need of acute NCS also has chest
pain or other symptoms suggestive of undetected
CAD, a multidisciplinary assessment approach is
recommended to choose the treatment with
lowest total risk for the patient.
I C
Dyspnoea and/or peripheral oedema
In patients with dyspnoea and/or peripheral
oedema, an ECG and an NT-proBNP/BNP test is
indicated before NCS, unless there is a certain
non-cardiac explanation.
I C
In patients with dyspnoea and/or peripheral
oedema and elevated NT-proBNP/BNP, TTE is
recommended before NCS.c
I C
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BNP, B-type natriuretic peptide; CAD, coronary artery disease; CVD, cardiovascular
disease; ECG, electrocardiogram; NCS, non-cardiac surgery; NT-proBNP, N-terminal
pro-B-type natriuretic peptide; TTE, transthoracic echocardiography.
aClass of recommendation.
bLevel of evidence.
cIf BNP/NT-proBNP testing is unavailable, TTE should be considered.
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4. Pre-operative assessment tools
4.1. Risk scores
4.1.1. General risk calculators
Several risk indices have been developed based on multivariable analyses
of observational data and have been validated during the last decade
(Table 6).47,49,76 Most risk calculators integrate both patient-related
and surgery-related risk factors, but none of them include biomarkers
among their variables. Calculators for most of the commonly used risk
indices are available online (Table 6). The risk calculators can be used in
addition, or as an alternative, to the assessment of surgery-related and
patient-related risk factors described in Section 3.3. The Task Force
decided against recommending one specific risk score. The Task Force
also decided that the selection criteria for further pre-operative testing
should be clinical criteria, and not based on a specific score.
Recommendation Table 5 — Recommendations for
patient information
Recommendations Classa Levelb
It is recommended to give patients individualized
instructions for pre-operative and post-operative
changes in medication, in verbal and written
formats with clear and concise directions.
I C
It should be considered to set up a structured
information list (e.g. a check list to help with
common issues) for patients with CVD or at high
risk of CV complications scheduled for NCS.
IIa C
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CV, cardiovascular; CVD, cardiovascular disease; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
Do I need to take any cardioprotective medication before surgery?
Who will inform my cardiologist about my surgery?
Do I need to pause or reduce any of my medications, and what are the risks if I do so?
Who will take care of me and how will they communicate my history and needs during my hospital stay?
Can my heart medications cause any problems during surgery?
Are there any interactions or contraindications between my medications and drugs given during surgery?
How will the healthcare professionals involved in my care be informed about my heart condition?
Can you give me information on how I will be monitored before, during, and after surgery?
Figure 3 Examples of questions and concerns expressed by patients.
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The RCRI estimates the risk of 30 day mortality, MI, or
cardiac arrest, and is based on six variables.46,47 It has been
validated in several countries and is easy to use.47 A score of
0 indicates a 4% risk of 30 day mortality, MI, or cardiac arrest; a
score of 1 indicates a 6% risk; a score of 2, 10%; and a score of
≥3, 15%.47
The American College of Surgery National Surgical Quality
Improvement Program (ACS NSQIP) developed an interactive risk
Table 6 Risk score calculators
Revised Cardiac
Risk Index (RCRI)
(1999)a
Surgical Risk
Calculator (2011)
The American College
of Surgery National
Surgical Quality
Improvement Program
(ACS NSQIP) (2013)
Surgical
Outcome
Risk Tool
(SORT)
(2014)
The American
University of Beirut
(AUB)-HAS2
Cardiovascular Risk
Index (2019)b
Variables Ischaemic heart
disease
Cerebrovascular
disease
History of congestive
heart failure
Insulin therapy for
diabetes
Serum creatinine level
≥2 mg/dL
High-risk surgery
(each assigned 1 point)
Age
ASA–PS grade
Pre-operative
dependent functional
status
Creatinine .1.5 mg/dL
Type of surgery
Age
Sex
Functional status
Emergency case
ASA class
Current steroid use
Ascites within 30 days
Systemic sepsis within 48 h
Ventilator dependence
Disseminated cancer
Diabetes
Hypertension on treatment
Congestive HF
Dyspnoea
Current smoker
History of severe COPD
Dialysis
Acute renal failure
Body mass index
Surgery code
ASA–PS grade
Urgency of
surgery
High-risk
surgical
specialty
Surgical severity
(from minor to
complex major)
Cancer
Age ≥65 years
or over
History of Heart disease
Symptoms of Heart
disease (angina or
dyspnoea)
Age ≥75 years
Anaemia (haemoglobin
,12 g/dL)
Vascular Surgery
Emergency Surgery
(2 H, 2 A and 2 S)
(each assigned 1 point)
Score range Score 1; risk 6.0%
(4.9–7.4)
Score 2; risk 10.1%
(8.1–10.6)
Score ≥3; risk 15%
(11.1–20.0)
Absolute risk: 0–100% Absolute risk: 0–100% Absolute risk:
0–100%
Low risk (score 0–1); (0.3
and 1.6%)c
Intermediate risk (score 2–
3); (7.1 and 17%)c
High risk (score .3);
(.17%)c
Outcome 30 day MI, cardiac
arrest, death
Intra-operative and 30
day MI or cardiac arrest
Serious complications and
any complications at 30 days
30 day
mortality
30 day death, MI, or stroke
Derivation
population
1422 211 410 1 414 006 11 219 3284
Validation
population
Externally validated in
various surgical
populations
257 385 Externally validated in
various surgical populations
22 631 1 167 414
Model
performance
(AUC)
0.68–0.76 0.81–0.85 0.73 0.81–0.92 0.82
Interactive
calculator
https://www.mdcalc.
com/revised-cardiac-
risk-index-pre-
operative-risk
http://www.
surgicalriskcalculator.
com/miorcardiacarrest
https://riskcalculator.facs.
org
http://www.
sortsurgery.
com
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AUC, area under curve; ASA–PS, American Society of Anesthesiology Physical Status; COPD, chronic obstructive pulmonary disease; HF, heart failure; MI, myocardial infarction; RCRI,
Revised Cardiac Risk Index.
aThe RCRI was updated January 2019.
bDakik et al. 2019, 2020, and 2022, and Msheik et al.49–51,81
cThe percentages relate to general surgeries.50
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calculator providing an estimate of the absolute 30 day probability of
serious complications and any complications compared with the
average patient.76 Evaluated in the US surgical database, the ACS
NSQIP model performed better than the RCRI, but an external val-
idation in the Philippines found both to have excellent discriminative
abilities for predicting any MACE.48 The RCRI can be used without a
web connection, whereas the ACS NSQIP is procedure-specific and
is only available on the web. For clinical use, the RCRI is more access-
ible, but the ACS NSQIP offers procedure-specific absolute risk es-
timates, which are valuable in patient-guided decision-making. In
vascular surgery, both risk calculators have shown moderate accur-
acy with an area under curve (AUC) of 0.64 (95% CI, 0.57–0.70) for
ACS NSQIP and 0.60 (95% CI, 0.54–0.65) for RCRI, due to under-
estimation of the risk of MI. Attempts to generate procedure-specific
vascular calculators have not given better predictions in validation
cohorts.77
The Surgical Outcome Risk Tool (SORT) estimates 30 day mortal-
ity after NCS based on the American Society of Anesthesiologists
Physical Status (ASA–PS) grade, urgency of surgery, surgical speciality
and severity, cancer, and age≥65 years. In the validation study, com-
bining subjective assessment with the SORT was significantly better
than using either alone.78,79 The Surgical Risk Calculator is another
tool that predicts intra-operative and 30 day risk of MI or cardiac ar-
rest based on age, ASA–PS grade, pre-operative dependent function-
al status, creatinine, and type of surgery.80
The American University of Beirut (AUB)-HAS2 Cardiovascular
Risk Index is the most recently developed index to assess 30 day
event risk (death, MI, or stroke), and stratifies patients undergoing
NCS into low (score 0–1), intermediate (score 2–3), and high risk
(score .3) based on six data elements (see Table 6); scores .3 de-
note a post-operative event rate of .10%.49 The AUB-HAS2 Index
has been tested in a broad spectrum of surgical subpopulations and
demonstrated superior discriminatory power compared with the
commonly utilized RCRI (Table 6).50,51,81
There is significant variability in the predicted risk of cardiac com-
plications using different risk-prediction tools; none can be disquali-
fied with current evidence.82
4.1.2. Frailty
Frailty is an age-related, multidimensional state of decreased physio-
logical reserve that results in diminished resiliency, loss of adaptive
capacity, and increased vulnerability to stressors.83,84 The peri-
operative evaluation of elderly patients (.70 years) who require
elective intermediate- or high-risk NCS should include frailty screen-
ing, which has proven to be an excellent predictor of unfavourable
health outcomes in the older surgical population.
Frailty has a relevant impact on mortality and MI risk but does not
add to risk estimation derived from the ACS NSQIP calculator, as
frailty is associated with variables already in the main model. By add-
ing six variables, the ACS NSQIP predicts the risk of post-operative
delirium, functional decline, need of a new mobility aid, or pressure
ulcer.85 The use of this broader-inclusive score identifies cases that
profit the most by involving a geriatrician in the pre- and post-
operative team.86,87 A measure of frailty informs the patient and sur-
geon about further life expectancy and the chance of post-operative
delirium, dependency of mobility support, and need of nursing home
or other care support after planned surgery.
Of the available screening tools for frailty, the Frailty Index and the
Frail Phenotype are the most commonly recommended.88,89 Of note,
the Frailty Index includes cognitive testing, while both scores assess
physical function.90,91 A simpler approach is offered by the Clinical
Frailty Scale, which relies on information from the history taking. The
Clinical Frailty Scale has been validated against the Frailty Index.88 For
cognitive screening to incorporate with the Frailty Index, Mini-Cog©
is a simple and fast screening tool validated for pre-operative screen-
ing92 (Supplementary data, Figure S1, and Tables S2 and S3).
Once a diagnosis of frailty is confirmed, the prognosis of a frail patient
can be improved by shared decision-making between at least a treating
physician (e.g. surgeon), anaesthesiologist, geriatrician, the patient, and
the patient’s relatives. During the shared decision-making process, a
careful discussion with a frail patient about goals of care could help
them to have realistic expectations and make better informed decisions
before surgery. After a shared decision to go aheadwith a plannedNCS,
multimodal pre-habilitation programmes—including exercise, nutrition,
and psychological interventions—could potentially improve the peri-
operative prognosis of frail patients by an individualized approach
tailored to the patient’s baseline functional status, comorbidities, and
cognitive/psychological function.90
4.2. Functional capacity
Quantifying functional capacity has been a pivotal step in pre-
operative cardiac risk assessment.10 Although the validity of
interview-based assessment of functional capacity has been ques-
tioned,93 a recent large prospective cohort study of high-risk patients
undergoing NCS found self-reported inability to climb two flights of
stairs added incremental value to the 30 day cardiac event rate when
added to the RCRI.94
Metabolic equivalents (METs) ,4 have long been considered to
indicate poor functional capacity; however, studies using METs
have been based on subjective interviews and not shown proven va-
lue. In the Measurement of Exercise Tolerance before Surgery
(METS) study, the Duke Activity Status Index (DASI) (https://www.
mdcalc.com/duke-activity-status-index-dasi#evidence) had a more
precise estimation of cardiac risk than subjectively assessed function-
al capacity, improving risk estimation using RCRI.95 A DASI score
,34 was associated with increased odds of 30 day death or MI.96
From the DASI score, METs can be calculated as VO2 max (maximal
oxygen consumption)/3.5; where VO2 max (mL/kg/min)= 0.43×
DASI+ 9.6. Furthermore, cardiopulmonary exercise testing
(CPET) did not predict 30 day mortality, post-operative MI, or car-
diac arrest.94,95 It should be noted that a relatively low number of pri-
mary outcome events limited the statistical power of the analysis.
Recommendation Table 6 — Recommendations for
pre-operative assessment of frailty and functional
capacity
Recommendations Classa Levelb
In patients aged ≥70 years and scheduled to
undergo intermediate- or high-risk NCS, frailty
screening should be considered using a validated
screening tool.84–87,90,91
IIa B
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4.3. Electrocardiography
The 12-lead ECG is a widely available, simple, and inexpensive tool
that is able to semi-quantitatively assess cardiac risk (e.g. Q waves in-
dicative of previous MI), and detect unknown CV conditions requir-
ing therapy (e.g. atrial fibrillation [AF] or AV-block).97–99 It is
recommended to obtain a pre-operative 12-lead ECG in patients
who are aged ≥65 years or have known CVD, CV risk factors, or
symptoms suggestive of cardiac disorders, and scheduled to undergo
intermediate- or high-risk surgery. It is not recommended to routine-
ly obtain a pre-operative ECG in low-risk patients undergoing low-
risk NCS.100
Comparison with previous ECG recordings is helpful whenever
relevant abnormalities are identified. Pre-operative recording of
ECG also enables identification of intra- and post-operative ECG
changes.
4.4. Biomarkers
As the peri-operative risk for cardiac complications depends on the
presence and extent of cardiac disease, widely available and simple
biomarkers that detect and quantify essential prognostic aspects of
cardiac involvement may aid in the evaluation. High-sensitivity cardiac
troponin T/I (Hs-cTn T/I) quantifies myocardial injury, and BNP and
NT-proBNP quantify haemodynamic cardiac wall stress (Figure 4).
Adjusting risk assessments according to
self-reported ability to climb two flights of stairs
should be considered in patients referred for
intermediate- or high-risk NCS.94
IIa B
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NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
0 1
hs-cTn
STEP 1
STEP 2
2 Days
ECG
Before NCS After NCSNCS
Δ hs-cTn
If no measurements 
available before NCS
Δ hs-cTn
Δ hs-cTn
PMI=If Δ hs-cTn ≥ ULN
STEP 3
ECG EchoClinical assessment
+ +
Identify the cause
of PMI
PMI
hs-cTn hs-cTn
Figure 4 Recommended measurements to assess and detect the risk of post-operative cardiac complications. ECG, electrocardiogram; hs-cTn, high-
sensitivity cardiac troponin; PMI, peri-operative myocardial infarction/injury; ULN, upper limit of normal. In patients scheduled to undergo intermediate- or
high-risk surgery, pre-operative risk assessment is complemented by ECG, hs-cTn, and BNP/NT-proBNP. An absolute increase in hs-cTn concentration of
more than the ULN on days 1 or 2 after surgery compared to the pre-operative level is defined as PMI.109–111 In the absence of a pre-operative hs-cTn T/I
concentration, a very high hs-cTn T/I concentration on day 1 (e.g. more than five-times theULN) or a relevant change from day 1 to day 2 (absolute increase
or decrease more than the ULN vs. day 1) would also achieve a reliable diagnosis of PMI. Detection of PMI should trigger ECG recording and detailed clinical
evaluation for PMI work-up and therapy. The differential diagnosis of PMI according to the fourth universal definition of MI is discussed in Section 8. The ESC
0/1/2 h algorithm has not been validated for the peri-operative setting and cannot be used here.
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Both Hs-cTn T/I and BNP/NT-proBNP complement clinical assess-
ment and ECG in risk prediction.9,52,53,101–103 Hs-cTn T/I and, to a
lesser extent, BNP/NT-proBNP concentrations are higher in pa-
tients with stress-induced myocardial ischaemia vs. those without,
and very low hs-cTn T/I concentrations achieve a very high negative
predictive value to rule out myocardial ischaemia.104–107
Several large prospective studies have shown that both hs-cTn T/I
and BNP/NT-proBNP have high and incremental prognostic value
for peri-operative cardiac complications, including CV death, cardiac
arrest, acute HF, and tachyarrhythmias. In a cohort of nearly 1000
subjects undergoing major elective NCS, individuals with pre-
operative hs-cTn T concentrations of .14 ng/L had an in-hospital
mortality of 6.9% vs. 1.2% in patients with hs-cTn T concentrations
≤14 ng/L (P, 0.001; AUC 0.81).53 In a large prospective cohort
study including 10 402 patients from 16 centres, NT-proBNP im-
proved risk predication beyond the RCRI.52 Among 1923 patients
undergoing NCS, NT-proBNP outperformed both RCRI and echo-
cardiographic parameters in the prediction of peri-operative CV
events.103 Overall, hs-cTn T/I and BNP/NT-proBNP seem to have
comparable accuracy in the prediction of cardiac complica-
tions.52,53,98–103,108 However, Hs-cTn T/I has four advantages over
BNP/NT-proBNP: (i) it is more widely available; (ii) it is less expen-
sive; (iii) if normal, it enables acute MI to be ruled out in the preceding
days; and (iv) availability of pre-operative hs-cTn T/I concentration
enables accurate diagnosis of PMI on Day 1 after surgery.109–111
See Section 8 for more details on diagnosis and treatment of PMI.
B-type natriuretic peptide/NT-proBNP has two advantages. First,
if elevated, evidence from randomized controlled screening studies
performed outside the peri-operative setting has supported the con-
cept that BNP/NT-proBNP-triggered cardiac work-up and intensifi-
cation of therapy improve outcomes.112,113 Second, HF is a
frequently undiagnosed condition in the elderly population most of-
ten undergoing NCS.47,114 Interpreting BNP/NT-proBNP concen-
trations as quantitative markers of HF with evolving rule-in cut-offs
may facilitate detection of HF, optimal intra-operative monitoring,
and initiation or optimization of HF therapy after surgery.114
To date, there is insufficient evidence in support of other CV bio-
markers for this specific indication.115,116
4.5. Non-invasive and invasive
procedures
4.5.1. Resting transthoracic echocardiography
In large retrospective cohorts, routine pre-operative TTE before
high-risk NCS did not reduce the risk of post-operative MACE or
provide more information than clinical risk models.120–122 Poor
exercise tolerance, abnormal ECG, suspected new or significant
CVDs without follow-up within the last 90 days, unexplained
dyspnoea, or coexisting clinical risk factors are appropriate
indications for TTE.123,124 Pre-operative TTE provides informa-
tion on three main risk markers for post-operative cardiac events:
LV dysfunction, VHDs, and cardiomyopathies. Left ventricular
systolic dysfunction is an important predictor of post-operative
HF.125 However, low ventricular ejection fraction is a
borderline independent predictor of major post-operative CV
complications.126–128
Pre-operative FOCUS examination—with a hand-held ultrasound
device for the assessment of murmurs, haemodynamic instability,
ventricular function, and dyspnea—may impact patient management
by improving the diagnostic accuracy of clinical assessment, and help
to triage candidates for standard TTE, plan surgery and anaesthesia
technique, and with post-operative monitoring.129–131 However,
current evidence remains mostly confined to uncontrolled or retro-
spective observational studies with no clear benefits on the outcome,
despite a favourable impact on peri-operative management.130,132 In
a multicentre randomized trial, preliminary results showed that pre-
operative FOCUS significantly reduced all-cause mortality.133
Notably, because of the lack of spectral Doppler capabilities, the
FOCUS examination is only accurate for assessing main structural
and functional abnormalities.
Patients with diastolic dysfunction are usually old, more hyperten-
sive, obese, diabetic, and likely to have AF or chronic renal disease.
Several studies with different clinical end-points have underlined
Recommendation Table 7 — Recommendations for
pre-operative risk assessment—electrocardiography
and biomarkers
Recommendations Classa Levelb
In patients who have known CVD or CV risk
factors (including age≥65 years), or symptoms or
signs suggestive of CVD it is recommended to
obtain a pre-operative 12-lead ECG before
intermediate- and high-risk NCS.97–99
I C
In patients who have known CVD, CV risk
factors (including age ≥65 years), or symptoms
suggestive of CVD it is recommended to
measure hs-cTn T or hs-cTn I before
intermediate- and high-risk NCS, and at 24 h and
48 h afterwards.53,105–107,109–111,117
I B
Continued
In patients who have known CVD, CV risk factors
(including age≥65 years), or symptoms suggestive
of CVD, it should be considered to measure BNP
orNT-proBNP before intermediate- and high-risk
NCS.52,104,112–114
IIa B
In low-risk patients undergoing low- and
intermediate-risk NCS, it is not recommended
to routinely obtain pre-operative ECG, hs-cTn T/I,
or BNP/NT-proBNP concentrations.109,111,117–119
III B
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BNP, B-type natriuretic peptide; CV, cardiovascular; CVD, cardiovascular disease; ECG,
electrocardiogram; hs-cTn I, high-sensitivity cardiac troponin; hs-cTn T, high-sensitivity
cardiac troponin T; NCS, non-cardiac surgery; NT-proBNP, N-terminal pro-BNP; ULN,
upper limit of normal.
Abnormal ECG: pathological Q wave, ST-T wave changes, non-sinus rhythm, left bundle
branch block. Abnormal pre-operative hs-cTn T/I: more than ULN. Age, sex, and known
cardiac disease should also be considered when interpreting the pre-operative
concentration.98
Abnormal BNP: ≥35 pg/mL; abnormal NT-proBNP: ≥125 pg/mL. BNP/NT-proBNP
should be interpreted as quantitative markers of heart failure, and also take into
account age, sex, obesity, and known cardiac disease.52,114 Please note that age, renal
dysfunction, and obesity are important confounders in the age group in which
measurement of BNP/NT-proBNP is recommended, while sex has less impact.
aClass of recommendation.
bLevel of evidence.
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the association of diastolic dysfunction with post-operative adverse
events, including pulmonary oedema, AF, and mortality.134–138 A
meta-analysis including 3876 patients undergoing NCS found pre-
operative diastolic dysfunction to be an independent risk factor for
pulmonary oedema, congestive HF, and MI after surgery.139
However, a recent retrospective study, including 7312 patients,
showed no association between the degree of diastolic
dysfunction and in-hospital mortality or hospital length of stay in
NCS patients.140 Awareness of diastolic dysfunction or high LV filling
pressure (e.g. pulmonary hypertension, left atrial volume, E/e′ ratio)
seems necessary to optimize peri-operative patient management;
however, evidence does not support screening for diastolic
dysfunction.
4.5.2. Stress tests
4.5.2.1. Exercise stress test
Physical exercise, using a treadmill or bicycle ergometer, provides an
estimate of functional capacity, evaluates blood pressure (BP) and
heart rate response, and detects myocardial ischaemia through
pathological ST-segment changes with poor sensitivity (61–73%)
and specificity (60–80%).146 An exercise stress test alone should
only be considered a valuable alternative to diagnose obstructive
CAD if non-invasive imaging tests are unavailable.146 An exercise
stress test is of no diagnostic value in patients with pre-existing
ST-segment abnormalities (i.e. left bundle branch block, paced
rhythm, Wolff–Parkinson–White [WPW] syndrome, ≥0.1 mV
ST-segment depression on resting ECG, or taking digitalis). In add-
ition, an exercise test is unsuitable for patients with limited exercise
capacity, owing to their inability to reach their target heart rate.
Therefore, an exercise stress test alone should only be considered
a valuable alternative to diagnose obstructive CAD if non-invasive
imaging tests are unavailable, or for assessing functional capacity
when clinical history is ambiguous.146
4.5.2.2. Stress imaging
The use of stress imaging is appropriate for risk assessment in pa-
tients with clinical risk factors and poor functional capacity.147,148
The choice of the test is driven by local expertise. Selection, optimal,
and safe performance of stress imaging should comply with related
guidelines and recommendations.146,148,149 Stress imaging is not re-
commended in patients undergoing urgent surgery or with an un-
stable clinical condition. Evidence on the role of stress imaging for
peri-operative risk prediction and patient management is largely
based on inducible ischaemia by pharmacological stress testing, al-
though no evidence indicates the superiority of pharmacological
stress to exercise stress imaging in patients who are able to perform
an adequate level of physical exercise. Several studies and
meta-analyses have consistently defined clinical utility of pharmaco-
logical stress imaging for peri-operative risk assessment in patients
undergoing NCS.150–154 Although RCTs related to post-operative
outcome are lacking, there are large-scale prospective studies show-
ing a risk-adjusted association of stress imaging results with peri-
operative cardiac complications.155–157
Studies and meta-analyses have demonstrated similar prognostic
value of stress echocardiography and myocardial perfusion imaging
for peri-operative risk assessment with slightly higher negative pre-
dictive value of stress echocardiography,152 but the overall accuracy
varies with ischaemic heart disease (IHD) prevalence.151 A
moderate-to-large perfusion defect on either test is highly sensitive
for post-operative cardiac events.152,158 Normal stress imaging ex-
ams without resting abnormalities have high negative predictive va-
lue.159,160 However, positive predictive value of stress imaging for
peri-operative cardiac events is relatively low and requires confirm-
ation by other tests.150,152,161
In a recent retrospective study including 4494 patients, dobuta-
mine stress echocardiography (DSE) provided modest incremental
predictive value for peri-operative CV complications over clinical
variables and was found to be useful as part of a stepwise approach
in the risk stratification of patients undergoing intermediate- to high-
risk NCS.157 The strongest predictors of post-operative adverse
events determined so far are significant ischaemia (more than four
ventricular segments) during DSE, ischaemic threshold (60% of age-
predicted maximal heart rate), and a history of congestive HF.162,163
A negative DSE without resting wall motion abnormality has ex-
cellent negative predictive value, even when target heart rate cannot
be achieved despite an aggressive DSE regimen.164 In asymptomatic
patients if functional capacity is unknown, stress echocardiography
also enables dynamic evaluation of LV systolic and diastolic function;
valvular diseases such as aortic valve stenosis (AS), mitral valve sten-
osis (MS), and hypertrophic obstructive cardiomyopathy; and pul-
monary hypertension 165 However, the role of DSE for risk
Recommendation Table 8 — Recommendations for
transthoracic echocardiography
Recommendations Classa Levelb
TTE is recommended in patients with poor
functional capacityc and/or high NT-proBNP/
BNP,d or if murmurs are detected before high-risk
NCS, in order to undertake risk-reduction
strategies.121,124,127,141–143
I B
TTE should be considered in patients with
suspected new CVD or unexplained signs or
symptoms before high-risk NCS.59,124,125
IIa B
TTE may be considered in patients with poor
functional capacity, abnormal ECG, high
NT-proBNP/BNP,d or ≥1 clinical risk factor
before intermediate-risk NCS.126–128
IIb B
To avoid delaying surgery, a FOCUS exam
performed by trained specialists may be
considered as an alternative to TTE for
pre-operative triage.129,130,132,133,144
IIb B
Routine pre-operative evaluation of LV function is
not recommended.122,145
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BNP, B-type natriuretic peptide; CVD, cardiovascular disease; ECG, electrocardiogram;
FOCUS, focused cardiac ultrasound; LV, left ventricular; NCS, non-cardiac surgery;
NT-proBNP, N-terminal pro-B-type natriuretic peptide; TTE, transthoracic
echocardiography.
aClass of recommendation.
bLevel of evidence.
cSee Section 4.2.
d≥125 pg/mL/35 pg/mL.
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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 undergo-
ing major NCS have demonstrated that, compared with fixed de-
fects, 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 with-
out clinical risk factors for adverse cardiac outcomes.154,159,160
Stress cardiac magnetic resonance (CMR) imaging and late gado-
linium 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 recom-
mended 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 qual-
ity.146 In addition, CCTA is recommended as an alternative to inva-
sive 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 obser-
vational studies. The Coronary Computed Tomographic
Angiography and Vascular Events in Noncardiac Surgery Patients
Cohort Evaluation (Coronary CTA VISION) trial prospectively in-
vestigated 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 tomog-
raphy angiography improved the risk estimation for the primary out-
come of post-operative CV death and non-fatal MI within 30 days,
although CCTA was associated with more than five times inappro-
priate risk overestimations among patients not experiencing the pri-
mary outcome. The predictive value of CCTA further improved
when associated with non-invasive functional testing, such as myo-
cardial perfusion imaging, with a positive and negative predictive va-
lue 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 asymp-
tomatic patients with no history of cardiac disease undergoing ca-
rotid 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 functional-
ly 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 CADmay be present in a
significant number of patients requiring NCS, indications for pre-
operative 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, ei-
ther 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.
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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
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5. General risk-reduction
strategies
5.1. Cardiovascular risk factors and
lifestyle interventions
Control of CV risk factors—including BP, dyslipidaemia, and diabetes
—is important before NCS. For pre-operative management of BP
and diabetes, see Sections 6.8 and 6.13, respectively.
While lifestyle modifications before intervention reduce the risk of
several peri-operative complications, the impact on CV complica-
tions has not been adequately explored. Of the lifestyle changes re-
commended before surgery, smoking cessation is the best
documented in RCTs. Smoking has been associated with a higher
rate of post-operative complications at 30 days.173,174 Reviews of
RCTs have shown an effect of smoking cessation up to 6 months
post-operatively, with a clear reduction in any post-operative com-
plications by hazard ratio (HR) 0.42 (95% CI, 0.27–0.65), particularly
wound infections (HR, 0.43; 95% CI, 0.21–0.85).173,175 Regarding
timing of cessation, reviews of observational studies have shown con-
sistent associations with better surgical outcome for cessation .4
weeks before surgery, with each additional week resulting in a fur-
ther improvement of 19%.176–178
Pre-operative exercise programmes have only been tested in small
RCTs, and recent reviews have shown a relative risk (RR) reduction
in post-operative complications of 67% (RR, 0.33; 95% CI, 0.17–
0.61).179 Referral to a pre-operative exercise programme may be
considered for patients scheduled for major or complex elective sur-
gery.176,179,180Weight reduction of obese patients immediately prior
to surgery is not recommended.
5.2. Pharmacological
5.2.1. Beta-blockers
Beta-blockers reduce myocardial oxygen consumption by reducing
contractile force and heart rate. Beta-blockers are also effective anti-
arrhythmic agents. In addition, some beta-blockers such as metopro-
lol have an effect on acute inflammatory responses by inhibiting
neutrophil hyperactivation in acute settings.184 These properties
mean that beta-blockers have been some of the most frequently
tested cardioprotective agents in patients undergoing NCS. Several
RCTs have evaluated the effects of peri-operative beta-blockade
on clinical end-points in patients with different risk profiles (see
Supplementary data, Section 3.1.1.). Type, dosing and titration, timing
of initiation, duration of beta-blocker therapy, type of surgery, and
risk profile of subjects significantly differ between studies, making
comparisons complex.
The question about pre-surgery initiation of beta-blockers has been
a matter of intense controversy (see Supplementary data, Section
3.1.1.1). The largest and latest trial on the topic, the Perioperative
Ischemic Evaluation (POISE-1) trial, enrolled 8351 patients with or
at risk of atherosclerotic disease, and not on beta-blockers before
NCS. Patients were randomized to extended-release metoprolol suc-
cinate 200 mg daily or placebo 185 Treatment was initiated 2–4 h
before surgery and maintained for 30 days. The primary outcome
(composite of CV death, non-fatal MI, and non-fatal cardiac arrest)
was significantly lower in the metoprolol arm (5.8% vs. 6.9% [P=
0.04]). Metoprolol was associated with significant reductions in MIs,
coronary revascularizations, and AF. However, the incidences of all-
cause death, stroke, and clinically significant hypotension or bradycar-
dia were significantly higher in the metoprolol arm. Post hoc analysis
showed that hypotension carried the greatest attributable risk of
death and stroke 186 The high dose of extended metoprolol might
have played a role in the adverse events seen at follow-up.
Several meta-analyses, systematic reviews, and observational stud-
ies have also been reported (see Supplementary data, Table S4).187–
189 Overall, initiation of beta-blockers before NCS was not asso-
ciated with a net clinical benefit in most analyses, but they might
be beneficial in patients with high CV risk profiles or who are under-
going high-risk surgical interventions (including vascular interven-
tions).188,190–192 When oral beta-blockade is initiated in CAD
patients who undergo NCS, the use of atenolol or bisoprolol as a
first choice may be considered.190,193–195
In patients who are on chronic beta-blocker therapy before
surgery, it is recommended to maintain these in the peri-operative
period. Increased mortality following pre-operative beta-blocker
withdrawal has been reported in five observational studies.190,196–199
Interruption of this therapy for .2 days post-operatively may double
the risk of AF.200
Post-operative tachycardia should initially lead to treatment of the
underlying cause— such as hypovolaemia, pain, blood loss, or infec-
tion—rather than simply increasing the beta-blocker dose. When
beta-blockers are indicated, the optimal duration of the peri-
operative beta-blockade cannot be derived from randomized trials.
According to a meta-analysis of RCTs including 14 967 patients,
beta-blockers can reduce the risk of post-operative AF after
NCS;201 however, this comes at the cost of an increased risk of
bradycardia, hypotension, and stroke.187
Recommendation Table 11— Recommendations for
lifestyle and cardiovascular risk factors
Recommendations Classa Levelb
Smoking cessation .4 weeks before NCS is
recommended to reduce post-operative
complications and mortality.181,182
I B
Control of CV risk factors—including blood
pressure, dyslipidaemia, and diabetes—is
recommended before NCS.173,176–178,183
I B
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CV, cardiovascular; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
Pre-operative ICA may be considered in stable
CCS patients undergoing elective surgical CEA.172
IIb B
Routine pre-operative ICA is not recommended
in stable CCS patients undergoing low- or
intermediate-risk NCS.
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CAD, coronary artery disease; CCS, chronic coronary syndrome; CCTA, coronary
computed tomography angiography; CEA, carotid endarterectomy; ICA, invasive
coronary angiography; NCS, non-cardiac surgery; NSTE-ACS, non-ST-segment
elevation acute coronary syndrome.
aClass of recommendation.
bLevel of evidence.
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The ultra-short-acting beta-blockers esmolol and landiolol have
the theoretical advantages of very fast onset of effects and short half-
lives. Notably, landiolol may lower BP to a lower extent than
esmolol. Evidence of prevention of AF with landiolol after NCS is
less robust and inconsistent than in the context of cardiac sur-
gery.202–205 The timing of the initiation of beta-blockers to prevent
AF remains unclear, with most prophylactic regimens using short-
acting agents being started intra-operatively.187
5.2.2. Amiodarone
Amiodarone is the most frequently used agent for prevention of
post-operative AF,206 with a risk reduction of 58% in NCS in a
meta-analysis evaluating different antiarrhythmic drugs (AADs), but
may induce relevant non-cardiac side effects.201 In another
meta-analysis, amiodarone (oral or intravenous [i.v.]) and beta-
blockers were equally effective in reducing post-operative AF.207 In
another prospective RCT, a combination of beta-blocker plus amio-
darone outperformed beta-blockers alone in reducing post-
operative AF.208 It should be noted that the two latter studies
were undertaken in patients undergoing cardiac surgery.
Overall, while preventive amiodarone seems to reduce the inci-
dence of AF, the clinical benefits associated with its routine use are
unclear.
5.2.3. Statins
Despite the wide-ranging use of statins in patients undergoing sur-
gery, RCTs assessing the effects of initiating statin therapy during
the peri-operative period are scarce. This should be viewed separ-
ately from patients already on statin therapy. The long-term use of
statins in patients with CVD or high risk of CVD is well-established.40
Observational data suggest a potential benefit of statins in the
peri-operative phase. In a large, retrospective, and observational co-
hort, which included 180 000 veterans undergoing NCS, the use of
statins on the day of or the day after surgery was associated with a
reduction in mortality (RR, 0.82; 95% CI, 0.75–0.89).209 Similar re-
sults were seen in a retrospective cohort study using hospital dis-
charge and pharmacy records.210 Although both studies used
propensity matching to reduce bias, these analyses are prone to con-
founding, especially when discharge and pharmacy records are used.
As such, RCTs give a more reliable effect estimation, for example: the
Lowering the Risk of Operative Complications Using Atorvastatin
Loading Dose (LOAD) trial studied 648 statin-naïve patients, of
whom 24% had a history of CVD and 49% had diabetes.211 In this
randomized, placebo-controlled trial, patients received a loading
dose of atorvastatin 80 mg within 18 h before surgery followed by
40 mg daily for 7 days. Use of atorvastatin did not reduce the risk
of major events (all-cause mortality, non-fatal MI, or stroke at 30
days [HR, 0.87; 95% CI, 0.60–1.26; P= 0.46]). However, the trial
was underpowered to draw definite conclusions. In addition, several
meta-analyses have shown ambiguous results and most studies are of
a limited size with less than 100 patients.212,213
Therefore, routine peri-operative initiation of statin therapy is
not recommended. However, in patients in whom statin use is al-
ready indicated, treatment should be considered peri-operatively,
particularly in patients scheduled for high-risk surgery (e.g. vascular
surgery).
5.2.4. Renin–angiotensin–aldosterone system
inhibitors
Data on peri-operative use of renin–angiotensin–aldosterone system
(RAAS) inhibitors are inconclusive. The majority of studies suggest
that continued use of RAAS inhibitors is associated with a higher
risk of peri-operative hypotension and, as a consequence, higher
use of vasopressors and inotropes. Furthermore, intra-operative
hypotension and its duration is associated with end-organ damage,
including kidney injury, myocardial damage, and stroke.214 In a small
trial of 275 subjects, randomized to either continuation of their
angiotensin-converting-enzyme inhibitors (ACEIs) or omission of
the final pre-operative ACEI dose, patients randomized to omission
of the last dose before surgery experienced intra-operative hypoten-
sion less frequently (76/137 [55%] vs. 95/138 [69%]) and vasopressor
use was less likely.215 On the other hand, post-operative hyperten-
sion was more frequent in the omission group. Furthermore, in an
observational cohort study consisting of 4802 patients undergoing
NCS and using an ACEI or angiotensin receptor blocker (ARB), dis-
continuation of these drugs in the 24 h before surgery was associated
with a lower risk of intra-operative hypotension (adjusted RR, 0.80;
95% CI, 0.72–0.93; P, 0.001), and associated with a reduction in the
composite end-point consisting of all-cause mortality, stroke, and MI
(adjusted RR, 0.82; 95% CI, 0.70–0.96; P= 0.01);216 8% of the pa-
tients in this cohort were diagnosed with HF, in whom RAAS inhibi-
tors are the cornerstone of medical therapy. A systematic review,
including nine studies (five RCTs and four cohort studies), revealed
that withholding ACEI/ARB on the morning of surgery was not asso-
ciated with mortality or MACE;217 however, it did confirm that with-
holding therapy was associated with less intra-operative hypotension
(OR, 0.63; 95% CI, 0.47–0.85). If an ACEI/ARB is withheld prior to
NCS, it should be restarted as soon as possible in order to prevent
unintended long-term omission. No data on peri-operative effects of
angiotensin receptor neprilysin inhibitors (ARNI) exist, but hypoten-
sion is more common compared with patients on ACEI.218
Some important RCTs in this field are ongoing: the impact of renin–
angiotensin system inhibitors continuation vs. discontinuation on out-
come after major surgery trial STOPorNOT219 (NCT03374449),
and the POISE-3 trial (NCT03505723) are both assessing a
hypotension-avoidance strategy vs. a hypertension-avoidance strategy
on the risk of vascular death and major vascular events in patients who
are followed for 30 days after NCS.
5.2.5. Calcium channel blockers
The effects of calcium channel blockers (CCBs) on the balance be-
tween myocardial oxygen supply and demand makes them theoret-
ically suitable for risk-reduction strategies. The relevance of
randomized trials assessing the peri-operative effects of CCBs is
limited by their small size, lack of risk stratification, and the absence
of systematic reporting of cardiac death and MI. A meta-analysis
pooled 11 randomized trials totalling 1007 patients.220 Treatment
with CCBs significantly reduced the number of episodes of
myocardial ischaemia and supraventricular tachycardia (SVT) in the
pooled analyses. However, the decrease in mortality and MI reached
statistical significance only when both end-points were combined
(RR, 0.35; 95% CI, 0.08–0.83; P= 0.02). In contrast, a matched case-
control study of 1000 patients undergoing acute or elective
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aortic aneurysm surgery suggested that dihydropyridine use was in-
dependently associated with an increased incidence of peri-operative
mortality.221 These observational data may be biased by the
indications for the use of CCBs. In patients already on CCBs,
particularly in those with vasospastic angina, it is recommended to
continue CCBs during the peri-operative period, but withholding
the dose on the day of surgery in order to avoid post-operative
hypotension.
5.2.6. Alpha-2 receptor agonists
Alpha-2 receptor agonists reduce post-ganglionic noradrenaline
output and might therefore reduce catecholamine surge during
surgery. The European Mivazerol trial randomized 1897 patients
with IHD who underwent intermediate- or high-risk NCS.222
Mivazerol did not decrease the incidence of death or MI in the
whole population. However, it did decrease the incidence of death
in a subpopulation of 904 patients undergoing vascular surgery.222
The international Peri-Operative ISchemic Evaluation 2 (POISE-2)
trial randomized 10 010 patients undergoing NCS to clonidine
or placebo.223 Clonidine did not reduce the rate of death or non-
fatal MI in general or in patients undergoing vascular surgery (RR,
1.08; 95% Cl, 0.93–1.26; P= 0.29), but it did increase the risk
of clinically important hypotension (RR, 1.32; 95% Cl, 1.24–1.40;
P, 0.001) and non-fatal cardiac arrest (RR, 3.20; 95% Cl, 1.17–
8.73; P= 0.02).
5.2.7. Diuretics
Diuretics are frequently used in patients with hypertension or HF. In
general, therapy for treatment of hypertension should be continued
to the day of surgery and resumed orally when possible. However,
the benefit for continuing diuretics as antihypertensive therapy is un-
clear, and alternative antihypertensive agents may be considered. In
HF, the dosage of diuretics should be adjusted well in advance for
an optimal fluid balance before surgery, and to avoid fluid retention
or dehydration.
The possibility of electrolyte disturbance should be considered in
any patient receiving diuretics. Hypokalaemia is reported to occur in
up to 36% of patients undergoing surgery (mostly NCS).224,225
Special attention should be given to patients prone to developing ar-
rhythmias. Any electrolyte disturbance, especially hypokalemia and
hypomagnesaemia, should be corrected in due time before surgery.
Acute pre-operative repletion in asymptomatic patients may be as-
sociated with more risks than benefits; thus, minor asymptomatic
electrolyte disturbances should not delay acute surgery.
In the peri-operative period, volume status in patients with HF
should be carefully monitored and optimized by loop diuretics or
fluids. However, retrospective data suggest that intra-operative pre-
scription of diuretics may increase the risk of acute kidney injury
(AKI) after NCS.226
5.2.8. Ivabradine
Heart rate is an independent and modifiable risk factor for peripro-
cedural MI (and maybe death) after NCS. Ivabradine is a negative
chronotropic agent without associated hypotensive effect, and is
therefore a possible alternative to beta-blockers. However, there
are few studies about the value of ivabradine for high-risk patients
undergoing NCS.227 The small (78 patients) PeRi-OperaTivE
CardioproTection With Ivabradine in Non-cardiac Surgery
(PROTECTIN) (NCT04436016) trial is ongoing.
5.2.9. Sodium–glucose co-transporter-2 inhibitors
The use of sodium–glucose co-transporter-2 (SGLT-2) inhibitors is
increasing, due to proven CV benefits for patients with type-2 dia-
betes mellitus (DM) and a beneficial effect on outcomes for patients
with HF and renal insufficiency. Euglycaemic diabetic ketoacidosis
(EDKA) is a rare but serious complication. While the incidence
was not significantly increased with SGLT-2 inhibitors in RCTs, sev-
eral case reports indicate that EDKA may occasionally occur after
(non-cardiac) surgery in patients on SGLT-2 inhibitors.228 A system-
atic review indicated that precipitating factors include diabetes medi-
cation changes, diet modifications, and intercurrent illnesses.229 The
US Food and Drug Administration (FDA) recommends interrupting
SGLT-2 inhibitor therapy for at least 3–4 days before scheduled sur-
gery and to be vigilant for symptoms related to EDKA, prompting
measurement of ketones.
Recommendation Table 12— Recommendations for
pharmacological treatment
Recommendations Classa Levelb
Initiation
In patients with an indication for statins, it should
be considered to initiate statins peri-operatively.
IIa C
Pre-operative initiation of beta-blockers in
advancec of high-risk NCS may be considered in
patients who have two or more clinical risk
factors,d in order to reduce the incidence of
peri-operative myocardial infarction.188,190–192
IIb A
Pre-operative initiation of beta-blocker in advance
of NCS may be considered in patients who have
known CAD or myocardial ischaemia.e,230–232
IIb B
Routine initiation of beta-blocker peri-operatively
is not recommended.185,187,189,233,234
III A
Continuation
Peri-operative continuation of beta-blockers is
recommended in patients currently receiving this
medication.190,196–199
I B
In patients already on statins, it is recommended
to continue statins during the peri-operative
period.235
I B
In patients with stable HF, peri-operative
continuation of RAAS inhibitors may be
considered.
IIb C
Continued
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5.3. Peri-operative handling of
antithrombotic agents
Management of patients taking antithrombotic agents and needing sur-
gery or an invasive procedure should consider patient- and
procedure-related risk of bleeding and thrombosis. Furthermore, the
pharmacokinetic and pharmacodynamic characteristics of the
antithrombotic drugs in use must be considered (Tables 7 and 8). The
risk of bleeding associated with different types of interventions is shown
in Table 9. Risk estimation and decision-making in patients requiring
long-term antithrombotic therapy is challenging, since relevant associa-
tions exist between peri-operative antithrombotic management, bleed-
ing, thrombotic events (MI and stroke), and mortality.6,11–13 Thus,
interdisciplinary risk assessment ahead of the intervention is cru-
cial, in order to classify the patient-related ischaemic and bleeding
risks (e.g. cardiologist, neurologist, vascular specialist, and haema-
tologist), and the surgical risk (surgeon and anaesthesiologist).
Information on timing of intervention by indicated duration of an-
tithrombotic therapy should be communicated with the patient
and treating general physician.
5.3.1. Antiplatelets
5.3.1.1. Single antiplatelet therapy
In patients taking aspirin for primary prevention, the risk of ischaemic
events is low and aspirin can be withdrawn prior to NCS. Permanent
discontinuation should be considered post-operatively in low- and
moderate-risk atherosclerotic cardiovascular disease (ASCVD) risk
patients and/or in patients with high bleeding risk based on
negative/neutral trials and the recommendations for primary preven-
tion of CVD in the 2021 ESC Guidelines on cardiovascular disease
prevention in clinical practice.40,241
Due to the better risk–benefit ratio, aspirin has an established role for
the long-term prevention of new cardiovascular events in patients with
establishedCVD.242 ThePOISE-2 trial is the largest, randomized, placebo-
controlled trial of peri-operative aspirin in patients undergoing NCS.243
Interruption
In patients without HF, withholding RAAS
inhibitors on the day of NCS should be considered
to prevent peri-operative hypotension.215,216
IIa B
For patients on diuretics to treat hypertension,
transient discontinuation of diuretics on the day of
NCS should be considered.236
IIa B
It should be considered to interrupt SGLT-2
inhibitor therapy for at least 3 days before
intermediate- and high-risk NCS.
IIa C
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b.p.m., beats per minute; CAD, coronary artery disease; HF, heart failure; NCS,
non-cardiac surgery; RAAS, renin–angiotensin–aldosterone system; RCRI, Revised
Cardiac Risk Index; SGLT-2, sodium-glucose co-transporter 2.
aClass of recommendation.
bLevel of evidence.
cIdeally at least 1 week before surgery, starting with a low dose with dose titration for
target heart rate.185,197,230,237 The target is a resting heart rate 60–70 b.p.m.191 with a
systolic blood pressure .100 mmHg.230,238
dIschaemic heart disease, cerebrovascular disease, renal insufficiency, or diabetes
mellitus, according to the RCRI score.239
eTreatment should ideally be initiated between 30 and (at least) 2 days before surgery,
starting at a low dose, and should be continued post-operatively.197,230,237
Table 7 Pharmacokinetic and pharmacodynamic characteristics of antiplatelets
ASA Clopidogrel Prasugrel Ticagrelor Cangrelor Eptifibatide Tirofiban
Target
(type of blockade)
COX-1
(irreversible)
P2Y12
(irreversible)
P2Y12
(irreversible)
P2Y12
(reversible)
P2Y12
(reversible)
GPIIB/IIIa
(reversible)
GPIIB/IIIa
(reversible)
Application Oral Oral Oral Oral i.v. i.v. i.v.
Time to Cmax 0.5–1.0 h 2 h
(after 600 mg LD)a
0.5 h
(after 60 mg
LD)a
0.5 h
(after 180 mg
LD)a
2 min 5 min 5 min
Prodrug No Yes Yes No No No No
Bioavailability (%) 50 50 80 36 100 100 100
Drug interactions NSAIDs
(in particular
ibuprofen +
naproxen)
CYP3A4, CYP3A5,
or CYP2C19
inhibitors or
inducers
CYP3A4/A5
and CYP2B6
inhibitor
CYP3A4
inducers or
inhibitors
None None None
Plasma half-life 20 min 0.5–1 h (active
metabolite)
0.5–1 h (active
metabolite)
6–12 h 3–6 min 2.5–2.8 h 1.2–2 h
Duration of action
after last dose
7–10 days 3–10 daysb 7–10 daysb 3–5 days 1–2 h 4 h 8 h
Renal clearance of
the active
metabolite (%)
NR NR NR NR 58 50 65
Dose regimen o.d. o.d. o.d. b.i.d. Bolus,
infusion
Bolus,
infusion
Bolus,
infusion ©
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ASA, acetylsalicylic acid; b.i.d., twice a day; Cmax, maximum serum concentration; i.v., intravenous; LD, loading dose; NR, non-relevant; o.d., once a day.
aTime to Cmax for may be delayed by 8 h or more following a dose of opiate.
bDepending on response status.
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Table 8 Pharmacokinetic and pharmacodynamic characteristics of oral anticoagulants
Warfarin Phenprocoumon Apixaban Dabigatran Edoxaban Rivaroxaban
Target
(type of
blockade)
VKORC1 VKORC1 FXa FIIa FXa FXa
Application Oral Oral Oral Oral Oral Oral
Time to Cmax 2–6 h 1.52 h+ 1.52 3–4 h 1.25–3 h 1–2 h 2–4 h
Prodrug No No No Yes No No
Bioavailability (%) .95 100 50 6.5 62 80–100
Drug interactions CYP2C9,
CYP2C19,
CYP2C8,
CYP2C18,
CYP1A2,
CYP3A4,
vitamin K
CYP2C9, CYP2C8,
vitamin K
CYP3A4 inhibitors
or inductors,
P-glycoprotein
inhibitors or
inductors
P-glycoprotein
inhibitors or
inductors
P-glycoprotein
inhibitors
CYP3A4 inhibitors
or inductors,
P-glycoprotein
inhibitors or
inductors
Plasma half-life 36–48 h 100 h 12 h 12–14 h 6–11 h 7–11 h (11–13 h in
the elderly)
Duration of action
after last dose
5 days 7 days 24 h 24 h 24 h 24 h
Renal clearance
of the active
metabolite (%)
Non-renal Non-renal 27 85 37–50 33
Dose regimen Adjusted
according to INR
Adjusted according
to INR
b.i.d. b.i.d. o.d. o.d./b.i.d.
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b.i.d., twice a day; Cmax, maximum serum concentration; FIIa, factor IIa; FXa, factor Xa; INR, International normalized ratio; LD, loading dose; NOAC, non-vitamin K antagonist oral
anticoagulant; o.d., once a day; VKORC1, vitamin K epoxide reductase complex 1.
Table 9 Bleeding risk according to type of non-cardiac surgery
Surgery with minor bleeding risk Surgery with low bleeding risk
(infrequent or with low clinical
impact)
Surgery with high bleeding risk
(frequent or with significant clinical
impact)
• Cataract or glaucoma procedure
• Dental procedures: extractions (1–3 teeth), periodontal
surgery, implant positioning, endodontic (root canal)
procedures, subgingival scaling/cleaning
• Endoscopy without biopsy or resection
• Superficial surgery (e.g. abscess incision, small skin excisions/
biopsy)
• Abdominal surgery: cholecystectomy,
hernia repair, colon resection
• Breast surgery
• Complex dental procedures (multiple
tooth extractions)
• Endoscopy with simple biopsy
• Gastroscopy or colonoscopy with
simple biopsy
• Large-bore needles procedures (e.g.
bone marrow or lymph node biopsy)
• Non-cataract ophthalmic surgery
• Small orthopaedic surgery (foot, hand
arthroscopy)
• Abdominal surgery with liver biopsy,
extracorporeal shockwave lithotripsy
• Extensive cancer surgery (e.g. pancreas,
liver)
• Neuraxial (spinal or epidural) anaesthesia
• Neurosurgery (intracranial, spinal)
• Major orthopaedic surgery
• Procedures with vascular organ biopsy
(kidney or prostate)
• Reconstructive plastic surgery
• Specific interventions (colon polypectomy,
lumbar puncture, endovascular aneurysm
repair)
• Thoracic surgery, lung resection surgery
• Urological surgery (prostatectomy,
bladder tumour resection)
• Vascular surgery (e.g. AAA repair, vascular
bypass) ©
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AAA, abdominal aortic aneurysm.
Adapted from Steffel et al.240
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The trial randomized 10 010 patients undergoing NCS with estab-
lished CVD, or who were at increased CV risk, to aspirin or placebo.
Patients were stratified according to whether they had not been tak-
ing aspirin before the study or were already on aspirin; 33% of the
patients had known vascular disease (23% CAD, 9% PAD, and 5%
stroke). Aspirin did not reduce the rates of death or non-fatal MI
at 30 days (7.0% vs. 7.1% in the placebo group [HR, 0.99; 95% CI,
0.86–1.15; P= 0.92]). Major bleeding was more common in the as-
pirin group than in the placebo group (4.6% vs. 3.8% [HR, 1.23; 95%
CI, 1.01–1.49; P= 0.04]). The primary outcome results were similar,
irrespective of whether or not patients had been taking aspirin be-
fore the study, and were also similar in patients with and without
vascular disease.
In a post hoc analysis of 470 patients (,5%) who had undergone
previous PCI, aspirin use was associated with a significant reduction
in death or MI (HR, 0.50; 95% CI, 0.26–0.95; P= 0.036) and MI alone
(HR, 0.44; 95% CI, 0.22–0.87; P= 0.021), while the risk of major or
life-threatening bleeding was not significantly increased in this set-
ting.244 Although the analysis carries several limitations, it supports
the perception that the ischaemic benefit of peri-operative aspirin
use outweighs the bleeding risk in patients with previous PCI.
Thus, among patients with previous PCI, in the absence of a very
high bleeding risk, low-dose aspirin should be continued during the
peri-operative period.
In patients undergoing transcatheter aortic valve implantation
(TAVI) who have no other indication for oral anticoagulant (OAC)
therapy, low-dose aspirin has been recommended as standard ther-
apy by recent guidelines based on an RCT.245,246 There are no ran-
domized data available assessing the withdrawal vs. continuation of
aspirin in patients after TAVI on aspirin alone undergoing NCS.
If the bleeding risk outweighs the potential CV benefit, aspirin
should be discontinued. For patients with high peri-operative bleed-
ing risk (e.g. undergoing spinal surgery or certain neurosurgical or
ophthalmological operations) aspirin should be discontinued for at
least 7 days.
On rare occasions, chronic coronary syndrome (CCS) patients
might be on clopidogrel monotherapy due to the results of recent
trials247 and the recommendations of the 2020 ESC Guidelines for
NCS-related bleeding risk
N
N
N
Patients on dual antiplatelet therapy
Y
Y
Y
High bleeding risk
related to NCS
High thrombotic risk:
PCI <1 month or 
ACS <3 months or
High risk of stent thrombosisa
Continue aspirin
(Class I)
Defer NCS
(Class I)
Time-sensitive NCS
Thrombotic risk
Recommendations
Continue DAPT
Ticagrelor: 3–5 days
Clopidogrel: 5 days
Prasugrel: 7 days
(Class I)
Bridge with GPI
or cangrelorc
Interrupt P2Y12
inhibitorb
(Class IIa/b)
Figure 5 Recommendations for management of antiplatelet therapy in patients undergoing non-cardiac surgery. ACS, acute coronary syndrome;
DAPT, dual antiplatelet therapy; GPI, glycoprotein IIb/IIIa inhibitors; PCI, percutaneous coronary intervention; N, no; NCS, non-cardiac surgery.
Y, yes; aHigh risk of peri-operative stent thrombosis defined by at least one of the following: history of stent thrombosis under antiplatelet therapy,
reduced left ventricular ejection fraction (,40%), poorly controlled diabetes, severely impaired renal function/haemodialysis, recent complex PCI (i.e.
severely calcified lesion, left main PCI, chronic total occlusion, bifurcational/crush technique, bypass graft PCI), or stent malapposition/residual dissection.
bTiming of resumption after interdisciplinary risk assessment as soon as possible (within 48 h) after surgery. cFor dosing, see Figure 7.
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the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation;98 therefore, periprocedur-
al management of clopidogrel-based single antiplatelet therapy
(SAPT) is required. Consensus has been reached that a short inter-
ruption of P2Y12 inhibitor monotherapy is recommended in patients
at high risk of bleeding.
Patients treated with P2Y12 inhibitor monotherapy as part of a de-
escalation strategy after PCI/ACS, or due to a recent stroke, PAD, or
aspirin intolerance, might require peri-operative management of this
monotherapy.248–250 A careful interdisciplinary evaluation of peri-
operative bleeding vs. ischaemic risk is warranted in these situations,
and individual decisions based on the peri-operative bleeding and is-
chaemic risk (e.g. surgery under P2Y12 monotherapy, switching to as-
pirin, short interruption, or bridging in the peri-operative phase) may
be applicable, although evidence for these different regimens is
missing. It should be recognized that the effects of ticagrelor or clo-
pidogrel monotherapy on haemostasis are considerably less than
when they are combined with aspirin.
5.3.1.2. Dual antiplatelet therapy
P2Y12 inhibitors in addition to aspirin are recommended for patients
after PCI.98,146 The frequency of major NCS in the first year after PCI
is 4%; most frequently orthopaedic, abdominal, and vascular sur-
gery.251 Other observational data report cumulative incidences of
NCS after PCI for 30 days, 6 months, and 1 year of 1%, 5%, and
9%, respectively.252
Observational studies have reported a substantial rate of MACE—
including cardiac death, MI, and stent thrombosis—ranging between
2–8%251,253,254 in PCI patients undergoing NCS, with a more than
two-fold increased risk compared with non-stented patients.255,256
N
P2Y12 inhibitor interruption after PCI before elective non-cardiac surgery
a
ACS at index PCI or other high ischaemic risk featuresb
Time from DAPT
initiation
Y
1 month
3 months
6 months
12 months
Class IIIc
Class IIad
Class Ie
Class IIIf
Class IIbg
Class IIah
Class Ii
Figure 6 P2Y12 inhibitor interruption after percutaneous coronary intervention before elective non-cardiac surgery. LoE, level of evidence; MI, myo-
cardial infarction; N, no; PCI, percutaneous coronary intervention. Y, yes; aAvailability of 24 h cath-lab service is suggested in case of major surgery within 6
months in non-ACS/non-high-risk patients and within 12 months in ACS/high-risk patients. bHigh risk of peri-operative stent thrombosis defined by at
least one of the following: history of recurrent MI, history of stent thrombosis under antiplatelet therapy, reduced left ventricular ejection fraction
(,40%), poorly controlled diabetes, severely impaired renal function/haemodialysis, recent complex PCI (i.e. severely calcified lesion, left main PCI, chronic
total occlusion, bifurcational/crush technique, bypass graft PCI), stent malapposition/residual dissection. cClass III LoE C. dClass IIa LoE B 250,265, 266,267.
eClass I LoE A 268,146. fClass III LoE B 269. gClass IIb LoE B 270, 271. hClass IIa LoE B 272,273,274, 275, 276,277,278. iClass I LoE A 279, 280, 281, 98.
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The proportion of risk attributable to underlying CVD or stent im-
plantation remains uncertain.254 Risk factors for MACE after NCS
are: time from PCI to surgery, with the highest risk in the first month;
primary PCI for ST-segment elevation myocardial infarction (STEMI);
dual antiplatelet therapy (DAPT) interruptions/discontinuation; and
lesion characteristics, including ostial and distal lesions.252,257–259
Urgency of surgery is a further risk factor. The ESC/ESA classification
of NCS is a validated tool with which to predict the impact of the
type of surgery on MACE.16
A meta-analysis of observational data indicated that discontinu-
ation of clopidogrel for at least 5 days reduced the risk of re-
operation for major bleeding by 50%, without increasing the risk
of MACE or death.260 Other observational data indicate an increase
in MACE with brief DAPT interruptions.261 However, these non-
randomized data may have been biased by the type and urgency of
surgery.260 Of note, the prognosis of stent thrombosis appears to
be worse than for de novo coronary occlusion (and depends on
the site of stent deployment), and premature interruption of
DAPT in patients with recent coronary stent implantation is the
strongest predictor for stent thrombosis.
The preferred management of patients on DAPT due to PCI is to
delay elective NCS until completion of the full course of DAPT
(6 months after elective PCI and 12 months after ACS).98,146
However, several recent trials have indicated that shortening
DAPT duration to 1–3 months after implantation of modern DES
is associated with acceptable rates of MACE and stent thrombosis
in low- and moderate-risk patients. Based on these newer data, it
is recommended to delay time-sensitive NCS until a minimum of
1 month of DAPT treatment has been effectuated. In high-risk CV
patients, for example due to an ACS, a DAPT duration of at least
3 months should be considered before time-sensitive NCS.
See Figure 5 for the recommended duration of DAPT before
Clopidogrel
(LD 300 mg),
followed by 75 mg o.d.
Infusion tirofiban/eptifibatidea
or restart tirofiban/eptifibatideb
Infusion cangrelorc
or restart cangrelorb
NCSPrasugrel Clopidogrel/ticagrelor
Clopidogrel
(LD 300 mg),
followed by 75 mg o.d.
STOPSTART
Prasugrel Clopidogrel/ticagrelor NCS
Day
Low dose ASA throughout
-7 -6 -5 -4 -3 -2 -1 -4–6 h 0 FU/
discharge
+4–6 h
Day -7 -6 -5 -4 -3 -2 -1 -1–6 h 0 FU/
discharge
+4–6 h
Low dose ASA throughout
Figure 7 Bridging with intravenous antiplatelet agents. ASA, acetylsalicylic acid; FU, follow-up; LD, loading dose; NCS, non-cardiac surgery; o.d., once a
day. aTirofiban: 0.1 µg/kg/min; if creatinine clearance,50 mL/min, adjust to 0.05 µg/kg/min. Eptifibatide: 2.0 µ/kg/min; if creatinine clearance is,50 mL/
min, adjust to 1.0 µg/kg/min. bUntil oral P2Y12 inhibitor therapy is possible.
cInitiate within 72 h from P2Y12 inhibitor discontinuation at a dose of 0.75 μg/
kg/min for a minimum of 48 h and a maximum of 7 days.
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time-sensitive NCS. Once the P2Y12 inhibitor has been discontinued,
surgery should be performed while the patient is still on aspirin.
Indications for long-term DAPT have recently emerged.
Long-term DAPT (beyond 1 year) with clopidogrel, prasugrel, or ti-
cagrelor in addition to aspirin should be considered in patients with
high ischaemic risk, and may be considered in patients with moderate
ischaemic risk, both in the absence of increased risk of major or life-
threatening bleeding.98 When NCS is required, discontinuation of
P2Y12 inhibitors is recommended for 3–7 days (depending on the
P2Y12 inhibitor) for these additional indications for DAPT.
5.3.1.3. De-escalation of antiplatelet effect
The management of antiplatelet therapy in patients who have under-
gone recent PCI and are scheduled for NCS should be discussed by
the surgeon and cardiologist, so that the balance between the risk
of life-threatening surgical bleeding on antiplatelet therapy—best
understood by the surgeon—and the risk of life-threatening stent
thrombosis due to premature DAPT discontinuation—best under-
stood by the cardiologist—can be considered (Figure 5 and Figure 6).
An increased risk of MACE as a consequence of (major) bleeding
also needs to be taken into consideration when balancing risk.
When time-sensitive surgery cannot be postponed and be per-
formed with the recommended DAPT on board, de-escalation or
shortening of DAPT is recommended. This may encompass either
a switch from the more potent P2Y12 inhibitors prasugrel or ticagre-
lor to clopidogrel, or cessation of aspirin and use of prasugrel or ti-
cagrelor monotherapy. If neither of these options is deemed to be
sufficient, premature discontinuation of the P2Y12 inhibitor may
be considered. If discontinuation is required, ticagrelor needs to be
withheld for 3–5 days, clopidogrel for 5 days, and prasugrel for 7
days prior to surgery.262–264
Whenever possible, in patients with an indication for DAPT, sur-
gery should be performed without discontinuation of aspirin. Aspirin
might be discontinued as a last measure only with very high bleeding
risk and a comparably low ischaemic risk. However, such surgical
procedures should be performed in hospitals where 24/7 catheter-
ization laboratories are available so as to treat patients immediately
in case of peri-operative ischaemic events.
Although generally not recommended, bridging with i.v. com-
pounds (eptifibatide/tirofiban or cangrelor) might be applicable in
rare cases when DAPT cannot be interrupted beforeNCS (e.g. in pa-
tients with very high risk of stent thrombosis, history of recurrent MI,
recent PCI) (see Figure 5 and Figure 7).282
For patients receiving antiplatelet therapy, who have excessive or
life-threatening peri-operative bleeding, transfusion of platelets is re-
commended as a bail-out strategy. However, ticagrelor and its active
metabolite may also inhibit aggregation of transfused platelets.
Experimental data indicate that administration of albumin binds tica-
grelor and reduces its inhibitory effect on platelet aggregation.283 A
monoclonal antibody fragment (PB2452) for neutralizing ticagrelor is
in development but is not yet clinically available.284
5.3.1.4. Platelet function guided peri-operative management of
antiplatelet therapy
Platelet function testing has several theoretical advantages in the
peri-operative setting, including: (i) the identification of patients on
antiplatelet therapy who are at increased risk of surgery-related
bleeding; (ii) individualized timing of elective surgery after antiplatelet
therapy cessation; and (iii) guiding therapy in bleeding complica-
tions.285–287 However, neither the optimal assay nor a universal cut-
off value associated with bleeding has been defined and validated in
patients undergoing NCS.
Recommendation Table 13— Recommendations for
use of antiplatelet therapy in patients undergoing non-
cardiac surgery
Recommendations Classa Levelb
It is recommended to delay elective NCS until 6
months after elective PCI and 12 months after an
ACS.264,271
I A
After elective PCI, it is recommended to delay
time-sensitive NCS until a minimum of 1 month of
DAPT treatment has been given.266,271,288,289
I B
In patients with a recent PCI scheduled for NCS, it
is recommended that management of antiplatelet
therapy is discussed between the surgeon,
anaesthesiologist, and cardiologist.
I C
In high-risk patients with a recent PCI (e.g. STEMI
patients or high-risk NSTE-ACS patients), a DAPT
duration of at least 3 months should be
considered before time-sensitive NCS.
IIa C
Continuation of medication
In patients with a previous PCI, it is recommended
to continue aspirin peri-operatively if the bleeding
risk allows.244
I B
Recommended time interval for drug interruption before
NCS
If interruption of P2Y12 inhibitor is indicated, it is
recommended to withhold ticagrelor for 3–5
days, clopidogrel for 5 days, and prasugrel for 7
days prior to NCS.262–264
I B
For patients undergoing high bleeding risk surgery
(e.g. intracranial, spinal neurosurgery, or
vitreoretinal eye surgery), it is recommended to
interrupt aspirin for at least 7 days
pre-operatively.
I C
In patients without a history of PCI, interruption
of aspirin at least 3 days before NCS may be
considered if the bleeding risk outweighs the
ischaemic risk, to reduce the risk of bleeding.243
IIb B
Resumption of medication
If antiplatelet therapy has been interrupted before
a surgical procedure, it is recommended to restart
therapy as soon as possible (within 48 h)
post-surgery, according to interdisciplinary risk
assessment.
I C
©
ES
C
20
22
ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; NCS, non-cardiac
surgery; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; PCI,
percutaneous coronary intervention; STEMI, ST-segment elevation myocardial
infarction.
aClass of recommendation.
bLevel of evidence.
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5.3.2. Oral anticoagulants
Approximately one in four patients taking anticoagulant therapy will
require a surgical or invasive procedure within 2 years.290
Peri-operative management of oral anticoagulant (OAC) therapy de-
pends on surgery- and patient-related factors and the specific OAC
agent (vitamin K antagonist [VKA] or a non-vitamin K antagonist oral
anticoagulant [NOAC]). See Figure 8 for a summary of recommenda-
tions for the management of OACs in patients undergoing NCS.
Surgery-related factors include urgency of the intervention and
the procedure-related bleeding risk (reflecting both the risk of bleed-
ing occurrence and the risk of adverse outcome if bleeding occurs)
(see Table 8). Procedures where mechanical compression is unfeas-
ible carry a high risk of serious bleeding complications.
Patient-related factors include age, individual thrombotic risk,
history of bleeding complications, renal function, concomitant
medication, comorbidity, etc. Patients requiring a reversal agent
need careful monitoring of haemostatic parameters and evalu-
ation of thrombotic and bleeding risk in the peri-operative
phase, as reversal might be insufficient or prothrombotic re-
bound might occur. In the latter case, an interdisciplinary deci-
sion should be made with regard to early resumption of
anticoagulation treatment.
5.3.2.1. Vitamin K antagonists
Three drugs are currently used: warfarin (half-life 36–48 h), aceno-
coumarol (half-life 12 h), and phenprocoumon (half-life 100 h).
5.3.2.1.1. Vitamin K antagonists in patients with mechanical heart
valves. Maintenance of therapeutic international normalized ratio
(INR) is crucial for patients with mechanical heart valves (MHVs).
N
N
N
Patients on oral anticoagulation therapy
Y
Y
Y
High bleeding risk NCS
VKA
VKA/
NOAC
Continue with INR
in lower level or
short interruption
(Class I)
Bridging is not
recommended 
(Class III)
Short interruptione
(Class I)
Bridging is not
recommended 
(Class III)
Interrupte
(Class I)
Bridging is not
recommended 
(Class III)
Defer NCSd
Possible
to defer NCS
High
thrombotic risk
Selected patients
with very high
thromboembolic riskb
Mechanical
heart valvea
NOACVKA
NCS-related
bleeding risk
Thrombotic risk
Recommendations
Bridgec
(Class IIa)
Bridgec
(Class IIb)
Figure 8 Recommendations for management of oral anticoagulation therapy in patients undergoing non-cardiac surgery. CHA2DS2-VASc, congestive
heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65–74 years, sex category (female); N, no; NCS, non-cardiac
surgery; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist; VTE, venous thromboembolism. Y, yes; aMechanical aortic valve
replacement (AVR) and any thromboembolic risk factor (atrial fibrillation, previous thromboembolism, severe left ventricular dysfunction, hypercoagul-
able state), or older-generation mechanical AVR, or a mechanical mitral valve replacement. bRecent stroke,3 months, high risk of VTE recurrences (e.g.
antithrombin 3 deficiency or protein C and/or S deficiency), left ventricular apex thrombus, atrial fibrillation with a very high stroke risk. cBridging with
unfractionated heparin or low molecular weight heparin. dE.g..3 months after stroke/VTE. eFor NOAC management during NCS, see Figures 9 and 10.
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Minor surgical procedures and procedures where bleeding is easily
controlled can be performed without VKA interruption. The INR
should be monitored and maintained at the lower level of the thera-
peutic range. Major surgical procedures needing INR ≤1.5 require
VKA interruption, and heparin bridging should be considered.
However, the evidence to support bridging therapy is limited and de-
rived from cohort studies with poor or no comparator groups.291
Furthermore, the current-generation mechanical prosthetic valves
in the aortic position are associated with a lower risk of thrombo-
embolism compared with the older ones.291 Randomized controlled
trials of bridging vs. no bridging therapy for patients with AF who do
not have an MHV have shown higher risk of bleeding without a
change in incidence of thromboembolic events, and increasing con-
cerns have been raised that bridging therapy exposes patients to
higher bleeding risks without reducing the risk of thromboembol-
ism.292,293 The recently published PERI-OP trial compared bridging
therapy vs. placebo in patients with either an MHV, AF, or atrial flut-
ter who required interruption of OAC therapy for surgery, and
found no significant benefit for post-operative dalteparin bridging
to prevent major thromboembolism.294 The results were consistent
for the AF (n= 1166) and MHVs groups (n= 350). Therefore, in pa-
tients with MHVs with a low risk of thromboembolism (e.g. mechan-
ical bileaflet aortic valve in patients with sinus rhythm), bridging may
not be needed. In patients with MHVs with a high risk of thrombo-
embolism (mechanical aortic valve replacement [AVR] and any
thromboembolic risk factor, or an older-generation mechanical
AVR, or a mechanical mitral or tricuspid valve replacement), bridging
with heparin should be considered during the peri-operative time
interval when the INR is subtherapeutic (Figure 8). In all situations,
the risks of bleeding should be weighed against the benefits of
thromboembolism prevention.
Intravenous unfractionated heparin (UFH) is the only heparin treat-
ment approved for bridging in patients with MHVs. Subcutaneous low
molecular weight heparin (LMWH), although used off-label, has sup-
planted the use of UFH as a bridging therapy, owing to the lower in-
cidence of thrombocytopenia, greater convenience, more predictable
dose–response relationship, and significant cost saving resulting from
outpatient administration. A meta-analysis of nine studies of 1042 pa-
tients withMHVs showed no differences between LMWHandUFH in
the risks of thromboembolic events or major bleeding events.295
When LMWH is used, it should be given at a therapeutic dose twice
a day and adjusted for renal impairment, when applicable. Anti-factor
Xa (FXa) activity monitoring with target levels from 0.5–1.0 U/mLmay
be useful when the dosage may be difficult to determine (e.g. in pa-
tients with renal dysfunction or obesity). Vitamin K antagonist bridging
strategies are shown in Supplementary data, Figure S2.
5.3.2.1.2. Vitamin K antagonists for atrial fibrillation/venous
thromboembolism. In patients using VKA for AF or venous
thromboembolism (VTE), invasive procedures with a low bleeding
risk can be performed without VKA interruption.296–299 The INR
should be monitored and maintained at the lower level of the thera-
peutic range. When interruption is necessary due to high bleeding
risk procedures, the BRIDGE trial in AF patients showed that 3–5
days of warfarin interruption without bridging was superior to heparin
bridging, having the same incidence of arterial and venous thrombo-
embolism and significantly lower incidence of major bleeding.292
Bridging therapy may be considered for patients with a high
thrombotic risk (i.e. AF with CHA2DS2-VASc (congestive heart fail-
ure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular
disease, age 65–74 years, sex category [female]) score .6, recent
cardioembolic stroke ,3 months, or high risk of VTE recurrence,
weighing the risk of bleeding against the risk of thromboembol-
ism291,294,300 (see Supplementary data, Figure S3).
5.3.2.1.3. Restarting vitamin K antagonists after invasive proce-
dures or surgery. Patients who have interrupted VKA treatment be-
fore surgery should restart the OAC 12–24 h after the invasive
procedure, if the bleeding is well-controlled and gastric and intestinal
reabsorption have been re-established. The restarting dose should
be the maintenance dose plus a boosting dose of 50% for 2 days.
Patients managed with bridging therapy should start LMWH or
UFH together with VKA 24 h after surgery, if the bleeding is well-
controlled and maintained, until the INR has reached the therapeutic
range. In patients undergoing surgery with a high bleeding risk, thera-
peutic dose LMWH should be delayed for 48–72 h after haemostasis
has been secured.
5.3.2.1.4. Reversal of vitamin K antagonists. Reversal of VKA can
be managed with vitamin K, prothrombin complex concentrates
(PPCs), and plasma administration. Vitamin K (from 2–10 mg de-
pending on the INR value) can be used orally, with a predictable
reduction in INR in 18–24 h or i.v. (in 25–50 mL normal saline
over 15–30 min) for more rapid INR reduction (4–6 h). It should
be noted that coagulation factors can still be below normal despite
INR normalization, which means that bleeding risk might not yet
be normalized. In patients needing reversal for immediate major sur-
gery, PPCs or plasma should be used. Four-factor PPCs are the pre-
ferred option301 and are dosed on the basis of INR and body weight
(INR 2–4 at 25 U/kg, INR 4–6 at 35 U/kg, INR.6 at 50 U/kg, with a
maximum dose of 5000 U at 100 kg of body weight). When four-
factor PPCs are unavailable, three-factor PPCs or plasma may be
used. Patients requiring a reversal agent need careful monitoring of
haemostatic parameters and evaluation of thrombotic and bleeding
risks in the peri-operative phase, as reversal might be insufficient
or a prothrombotic rebound might occur. In the latter case, an inter-
disciplinary decision should be made with regard to early resumption
of anticoagulation treatment.
5.3.2.2. Non-vitamin K antagonist oral anticoagulants
Four drugs are currently used: dabigatran (factor IIa inhibitor), apix-
aban, rivaroxaban, and edoxaban (FXa inhibitors). The pharmacoki-
netic and pharmacodynamic characteristics of these drugs are shown
in Table 8.
5.3.2.2.1. Unplanned surgery in patients on non-vitamin K antag-
onist oral anticoagulants and reversal for emergency procedures.
When an urgent surgical intervention is required, it is recommended
that NOAC therapy is immediately interrupted. Peri-operative man-
agement of NOAC therapy in specific procedural settings and sug-
gested strategies for potential reversal of NOAC anticoagulant
effect are shown in Figures 9–1199,240,302 (see Supplementary data,
Table S5).
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Whereas the open-label prospective trial testing the specific re-
versal agent idarucizumab in patients on dabigatran enrolled partici-
pants experiencing acute major bleeding or requiring urgent surgical
intervention,303 the trial with the reversal agent andexanet alpha for
FXa inhibitors included only patients with acute major bleeding un-
der therapy, but not those requiring urgent surgery.304 However,
the off-label use of andexanet alpha in life-threatening situations re-
quiring an immediate intervention may be considered, bearing in
mind that andexanet alpha non-specifically binds all FXa inhibitors,
which may have important implications for further treatment, includ-
ing the administration of UFH or LMWH.240 When specific reversal
agents are unavailable, prothrombin complex concentrate (PCC) or
activated PCC should be considered, although there is a lack of evi-
dence on their efficacy and safety for emergency procedures in pa-
tients taking a NOAC.290,305 Performing immediate or urgent
surgery under general rather than spinal anaesthesia is prudent, in or-
der to reduce the risk of epidural haematoma.
Prior to unplanned surgery, the full panel of coagulation blood
tests (see Supplementary data, Table S6) should be obtained in order
to assess the patient’s coagulation status. The indication for reversal
(and/or non-specific haemostatic) agents is primarily governed by the
patient’s clinical presentation, but initial assessment of coagulation
Stopping and re-initiation of NOAC therapy in elective NCS according
to the periprocedural risk of bleeding in patients with normal renal function
NOAC type Frequency of NOAC administration
-3 -2 -1
NCS
1 2
STOPSTART
Days
Rivaroxaban
Edoxaban
Low 
bleeding
risk NCS
Dabigatran
Apixaban
Twice
daily
Once
daily
Twice
daily
Once
daily
No NOAC
No bridgingc
Twice
daily
Once
daily
Twice
daily
Consider
restarting
NOAC in the
evening
Once
daily
Rivaroxaban
Edoxaban
High 
bleeding
risk NCS
Dabigatran
Apixaban
Twice
daily
Once
daily
Restart
NOAC
≥48–72 h
after surgery
No NOAC
Consider prophylactic
dose heparin
post-operatively
No NOAC
No bridgingc
Rivaroxaban
Edoxaban
Minor 
bleeding
risk NCS
Dabigatran
Apixaban
Twice
daily
Once
daily
Twice
daily
Once
daily
May skip the
evening dosea
Once
dailyb
Twice
daily
Once
daily
Twice
daily
Restart
NOAC ≥6 h
after surgery
Once
daily
Figure 9 Peri-operative management of non-vitamin K antagonist oral anticoagulant according to the periprocedural risk of bleeding. NCS, non-cardiac sur-
gery; NOAC, non-vitamin K antagonist oral anticoagulant. aIn patients/circumstances favouring NOAC accumulation (e.g. renal dysfunction, older age, concomi-
tant medication), theNOAC should be paused 12–24 h earlier. bIn patients on rivaroxaban or edoxaban taking the dose in the evening, the evening dosemay be
skipped. cNOACs have predictable weaning of the anticoagulant effect. Owing to the increase in bleeding risk associated with bridging, it is generally not re-
commended to use bridging in patients taking NOACs. Very few circumstances when bridging with heparin may be considered in patients taking a NOAC
include high thromboembolic risk conditions, such as: 1) patients with a recent (within 3 months) thromboembolic event (stroke, systemic embolism, or
VTE); 2) patients who experienced a thromboembolic event during previous interruption of NOAC therapy.
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status may have important implications for treatment in the next few
hours or days. Specific coagulation tests such as diluted thrombin
time (dTT) or ecarin clotting assay for dabigatran and antiFXa
chromogenic assays for FXa inhibitors, and the assessment of
NOAC plasma levels, may help in interpreting routine coagulation
tests and waning of anticoagulant effect.240
5.3.2.2.2. Planned interventions in patients on non-vitamin K oral
anticoagulants. Invasive surgical interventions may require tempor-
ary discontinuation of NOAC therapy, while many less-invasive pro-
cedures with a relatively low risk of bleeding may be performed under
minimally interrupted or uninterrupted NOAC therapy (Figure 9).240
5.3.2.2.3. Bridging. In patients taking a NOAC, peri-operative bridg-
ing using heparin or LMWH was associated with increased risk of
bleeding without reduction in thromboembolic events.290,306–308
Therefore, when NOAC interruption is required for surgery, bridging
is not recommended, except in a few high thrombotic risk circum-
stances (see Figure 9). However, post-operative thromboprophylaxis
with LMWH should be considered in patients in whom NOAC ther-
apy cannot be quickly restarted. In patients receiving bridging with
LMWH, monitoring of antiFXa activity and dose adjustment to a tar-
get level of 0.5–1.0 U/mL may be considered.
5.3.2.2.4. Laboratory testing before surgery. Pre-operative assess-
ment of anticoagulation status in patients on a NOAC undergoing
planned surgery provides a direct assessment of residual drug con-
centration. Shorter NOAC interruption time intervals in patients
undergoing low-risk procedures may result in mildly or moderately
elevated NOAC levels, as seen in the Perioperative Anticoagulant
Use for Surgery Evaluation (PAUSE) trial,309 whereas creatinine clear-
ance ,50 mL/min, standard NOAC dose (compared with reduced
dose), body weight ,70 kg, and female sex were associated with ele-
vated NOAC levels among patients undergoing high-risk surgery.
Apixaban, rivaroxaban, edoxaban
Low bleeding
risk NCS
High bleeding
risk NCS
Dabigatran
Low bleeding
risk NCS
Renal function
High bleeding
risk NCS
≥24 h≥80 ≥48 h
≥36 h50–79 ≥72 h ≥24 h
≥48 h30–49 ≥96 h
Not indicated15–29 Not indicated ≥36 h
<15 No formal indication for use
≥48 h
Timing of last NOAC dose before elective NCS
according to renal function
Minor bleeding risk NCS
No peri-operative bridging with UFH/LMWH
(estimated GFR, mL/min)
Low and high bleeding risk NCS
Perform intervention at NOAC through level (i.e. 12 h or 24 h after last intake for twice
or once daily regimens, respectively). Resume same day or latest next day.
Figure 10 Timing of last non-vitamin K antagonist oral anticoagulant dose before elective NCS according to renal function. GFR, glomerular filtration rate;
LMWH, low molecular weight heparin; NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral anticoagulant; UFH, unfractionated heparin.
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The use of amiodarone, verapamil, or diltiazemwas also associated with
elevated pre-operative NOAC levels in the prospective Per-procedural
Concentration of Direct Oral Anticoagulants (CORIDA) trial.310
Importantly, elevated NOAC levels were not found to be independ-
ently associated with bleeding complications.309,310
The evidence base for modifying the duration of pre-operative
NOAC interruption time intervals according to residual NOAC plas-
ma levels is unavailable, and ‘safe’ plasma levels of NOACs for differ-
ent procedures are largely unknown. The time-based NOAC
interruption (Figure 9) appears safe in most patients undergoing sur-
gery.311,312 When NOACs are interrupted for.72 h, the likelihood
of any residual NOAC plasma levels is very low.309,310
5.3.2.2.5. Considerations for specific procedures. Before interven-
tions that carry a very high risk of bleeding—such as spinal or epidural
anaesthesia, or lumbar puncture requiring intact haemostasis-–interrup-
tion of NOACs for up to five half-lives (i.e. 3 days for FXa inhibitors or
4–5 days for dabigatran) should be considered, whereas NOACs can
usually be restarted 24 h after the intervention.313,314
Dental procedures are generally considered to be associated with
minor bleeding risk, and adequate local haemostasis is usually easily
achieved. Hence, most dental procedures can be performed in an
outpatient setting, with uninterrupted NOAC (or a single skipped
dose) and using specific local haemostatic measures (such as the ap-
plication of oxidized cellulose or absorbable gelatine sponge, sutures,
Strategy for potential reversal of non-vitamin K oral anticoagulants effect
Perform NCSPerform NCS
Targeted haemostatic measures
Perform NCS
NNN YYY
Degree of urgency
Last intake of NOACs >12 hc
Check for blood coagulation tests:
full coagulation panel (PT, aPTT, antiFXa, dTT, etc.)
Measurement of NOAC plasma levels, if available
Recheck coagulation panel if last NOAC intake <12 h,c
or initial coagulation tests pathological,
or clinically relevant bleeding situation
Surgery deferral for 12 h,c
if safe, or after normalization
of coagulation parameterse
Reversal of NOAC depending on:
Surgery deferral as for planned
procedures, if safe (see Figure 8)
Surgery-related bleeding risk
and
agent availabilityd
IMMEDIATE
i.e. within minutes
URGENT
i.e. within hoursa
TIME-SENSITIVE
i.e. within daysb
Step 1
Urgency
Step 2
Blood coagulation
Step 3
Timing last NOAC
Step 4
NCS
Step 5
Recheck blood coagulation
Figure 11 Suggested strategy for potential reversal of non-vitamin K oral anticoagulants effect. aPTT, activated partial thromboplastin time; dTT, diluted
thrombin time; FXa, factor Xa; N, no; NOAC, non-vitamin K antagonist oral anticoagulant; PT, prothrombin time; UFH, unfractionated heparin. Y, yes;
aConditions that are potentially life-threatening or that may threaten the survival of limb or organ. bConditions that can be managed and procedure de-
layed for several days. c.24 h in case of significantly reduced renal function (i.e. eGFR ,50 mL/min). dIf specific reversal agent is unavailable, consider
non-specific haemostatic agents (prothrombin complex concentrate [PCC] or activated PCC [aPCCs]). Idarucizumab has only been tested in patients
undergoing urgent surgery. Andexanet has not been tested in patients requiring urgent surgery. Andexanet binds all FXa inhibitors (including UFH) non-
specifically. eUpon re-check.
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tranexamic acid mouthwash or compressive gauze). Most profes-
sional statements on dental surgery advise uninterrupted NOAC,
but these recommendations are mostly based on expert consensus,
while some studies are currently ongoing.315–317
5.3.2.2.6. When to restart non-vitamin K antagonist oral anticoa-
gulants after interventions. In general, NOAC can be restarted
6–8 h after interventions with rapid and complete haemostasis.
When the bleeding risk with full-dose anticoagulation resumption
outweighs the risk of thromboembolic events, therapeutic antic-
oagulation may be postponed to .48–72 h after the procedure,
using prophylactic post-operative thromboprophylaxis until the
resumption of full-dose NOAC is deemed safe (Figure 9).240
Post-operative heparin administration should also be considered in pa-
tients unable to take oral therapy. Off-label use of reduced-dose
NOACs to attenuate the risk of post-operative bleeding is not recom-
mended, as there is no evidence informing such an approach.
5.3.2.3. Combination therapy (antiplatelet and anticoagulant)
In general, according to the 2020 ESC Guidelines for the diagnosis
and management of atrial fibrillation developed in collaboration
with the European Association for Cardio-Thoracic Surgery
(EACTS), dual antithrombotic therapy should be adopted in most
patients with AF and a recent PCI.99 Elective surgery should be post-
poned until the period when antiplatelet therapy can be safely dis-
continued in combination therapy (6 months after elective PCI or
12 months after ACS).268 Peri-operative handling of NOACs should
follow the above recommendations (Figures 9 and 10). In urgent/
emergency surgery with high bleeding risk, operative measures to re-
duce bleeding and/or reversal strategies of anticoagulation might be
applied. In patients receiving combination therapy for other indica-
tions (e.g. TAVI and AF), according to recent trial results, antiplatelet
therapy can be safely discontinued before NCS.318 In patients receiv-
ing low-dose OACs as part of a vascular protection strategy, rivarox-
aban should be paused for at least 24 h before surgery and resumed
according to the post-operative bleeding risk.
Recommendation Table 14— Recommendations for
interruption and resumption of anticoagulants in pa-
tients undergoing non-cardiac surgery
Recommendations Classa Levelb
Interruption of anticoagulation
When an urgent surgical intervention is required,
it is recommended that NOAC therapy is
immediately interrupted.
I C
Idarucizumab should be considered in patients on
dabigatran and requiring urgent surgical
intervention with intermediate to high bleeding
risk.303
IIa B
Continued
In non-minor bleeding risk procedures in patients
using a NOAC, it is recommended to use an
interruption regimen based on the NOAC
compound, renal function, and bleeding risk.310,311
I B
For interventions with a very high risk of bleeding,
such as spinal or epidural anaesthesia, interruption
of NOACs for up to five half-lives and re-initiation
after 24 h should be considered.
IIa C
When specific reversal agents are unavailable,
PCC or activated PCC should be considered for
reversing NOAC effects.
IIa C
If an urgent surgical intervention is required,
specific coagulation tests and assessment of
NOAC plasma levels should be considered to
interpret routine coagulation tests and waning of
anticoagulant effect.
IIa C
Continuation of medication
In minor bleeding risk surgery and other
procedures where bleeding can be easily
controlled, it is recommended to perform surgery
without interruption of OAC therapy.240,296–299
I B
LMWH is recommended, as an alternative to
UFH, for bridging in patients with MHVs and high
surgical risk.295
I B
In patients using NOACs, it is recommended that
minor bleeding risk procedures are performed at
trough levels (typically 12–24 h after last intake).
I C
For patients with mechanical prosthetic heart
valves undergoing NCS, bridging with UFH or
LMWH should be considered if OAC interruption
is needed and patients have: (i) mechanical AVR
and any thromboembolic risk factor; (ii)
old-generation mechanical AVR; or (iii)
mechanical mitral or tricuspid valve replacement.
IIa C
Bridging of OAC therapy is not recommended in
patients with low/moderate thrombotic risk
undergoing NCS.290,292,293,306–308,311
III B
Start/resumption of medication
If bleeding risk with resumption of full-dose
anticoagulation outweighs the risk of
thromboembolic events, postponing therapeutic
anticoagulation 48–72 h after the procedure may
be considered, using post-operative
thromboprophylaxis until resumption of full OAC
dose is deemed safe.
IIb C
Use of reduced-dose NOAC to attenuate the risk
of post-operative bleeding is not recommended.
III C
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AVR, aortic valve replacement; OAC, oral anticoagulant; LMWH, low molecular weight
heparin; MHV, mechanical heart valve; NCS, non-cardiac surgery; NOAC, non-vitamin
K oral anticoagulant; PCC, prothrombin complex concentrate; UFH, unfractionated
heparin.
aClass of recommendation.
bLevel of evidence.
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5.4. Peri-operative thromboprophylaxis
Trends show that the case-fatality of peri-operative VTE has declined
over the past few decades.319,320 Its causal relationship with prevent-
able mortality has been challenged by a recent meta-analysis.321
Thus, peri-operative VTE should be regarded as a marker of in-
creased mortality risk rather than a causal factor. Careful pre-
operative assessment is essential to identify patients with increased
VTE risk who might benefit from peri-operative thromboprophy-
laxis. Procedure-related (e.g. type of surgery and likelihood of post-
operative immobilization) and patient-related factors contribute to
the risk of VTE. For non-orthopaedic surgical patients at low risk
of VTE, mechanical methods of VTE prophylaxis (graduated com-
pression stockings, intermittent pneumatic compression, or venous
foot pump) rather than pharmacologic prophylaxis or no prophylaxis
are recommended. Patients with CV disease (e.g. patients with re-
cent MI or HF) have increased risk of peri-operative VTE.322 The
Caprini score has been developed for risk stratification,323 and vali-
dated in different surgical settings (see Supplementary data,
Table S7).324–327
Thromboprophylaxis should be considered for patients with
moderate (i.e. 5–8 points) and high scores (i.e. ≥9 points).
Thromboprophylaxis should be initiated during the hospital stay until
12 h before NCS and continued post-operatively based on individual
risk assessment for bleeding. In most cases, thromboprophylaxis
should be continued until the patient becomes fully mobilized or until
hospital discharge (usually up to 10 days). Extended pharmacological
VTE prophylaxis beyond discharge is not routinely recommended in
most non-orthopaedic surgical patients. Although there are insuffi-
cient data regarding thromboprophylaxis after cancer surgery (par-
ticularly major abdominal and/or pelvic surgery for cancer), the
consensus is to extend treatment duration with preferred use of
LMWH for 3–4 weeks. Decisions on prophylaxis in populations
for which the Caprini score has not been validated (such as ortho-
paedic surgery) should be based on individual and procedure-specific
risk factors. Among those, a previous VTE is the strongest risk pre-
dictor (see Supplementary data, Table S7).328 For special situations
and populations (e.g. neurosurgery, elderly, obese), please refer to
available specific practice guidelines.329–332
Large phase 3 and phase 4 studies comparing NOACs with
LMWH have shown similar results regarding efficacy and safety after
major orthopaedic surgery.333 The usual time period for thrombo-
prophylaxis after total knee and hip arthroplasty was up to 14 days
and 35 days in RCTs, respectively,334–339 but large-scale data suggest
safety of foreshortening the duration restricted to the hospital stay
after fast-track surgery.340 Recent practice guidelines and a
meta-analysis suggest a rationale for the use of aspirin as thrombo-
prophylaxis in modern elective total hip and knee arthroplasty.341,342
However, there is a need for more adequately powered clinical trials
with appropriate end-points comparing aspirin with other pharma-
cological methods. Aspirin should not be used as the sole initial agent
for VTE prophylaxis, but switching to aspirin following a short course
(e.g. 5 days) of rivaroxaban may be suitable for selected low-risk pa-
tients.343 It is recommended to implement patient care programmes
—including post-operative mobilization, electronic prophylaxis re-
commendations, and teaching sessions regarding daily use of throm-
boprophylaxis—as these have been shown to be beneficial in
reducing the risk of post-operative VTE complications.344
5.5. Patient blood management
Major surgery is associated with a high risk of peri-operative blood
loss. Preferred treatment of acute anaemia related to peri-operative
blood loss is transfusion of allogenic blood products. However, a
large body of evidence indicates that inappropriate transfusion of
red blood cells (RBCs) may be associated with inherent complica-
tions and impaired surgical outcome. Therefore, it is important to
identify at-risk patients pre-operatively and manage peri-operative
bleeding in any patients undergoing major surgery.
A hallmark study including .200 000 major surgical patients
showed that even mild anaemia significantly increased the risk of
morbidity—including respiratory, urinary, wound, septic, and
thromboembolic complications—and mortality across all age
groups.345 Moreover, Baron and colleagues analysed.39 000 surgi-
cal patients and showed that anaemia was significantly associated
with increased mortality rate, hospital length of stay, and post-
operative admission to intensive care.346 Up to 48% of surgical
patients suffer from anaemia, and therefore anaemia should be con-
sidered to be a risk factor any time during hospitalization.347 Von
Heymann and colleagues analysed 4494 cardiac surgical patients
and showed that pre-operative anaemia and intra-operative transfu-
sion were independently associated with decreased long-term
survival.348 In addition, long-term survival was decreased by 50% in
anaemic patients receiving blood transfusion compared with those
without blood transfusion.
Anaemia may contribute to myocardial ischaemia, particularly if
CAD is present. Iron deficiency (ID) is the underlying cause of an-
aemia in 50% of all cases.347 It was recently shown that ID was as-
sociated with increased risk of 90 day mortality both in patients with
(4–14%) and without (2–5%) anaemia.349 In addition, the incidence
Recommendation Table 15— Recommendations for
thromboprophylaxis
Recommendations Classa Levelb
It is recommended that decisions about
peri-operative thromboprophylaxis in NCS are
based on individual and procedure-specific risk
factors.328,332
I A
If thromboprophylaxis is deemed necessary, it is
recommended to choose the type and duration of
thromboprophylaxis (LMWH, NOAC, or
fondaparinux) according to type of NCS, duration
of immobilization, and patient-related
factors.328,332
I A
In patients with a low bleeding risk, peri-operative
thromboprophylaxis should be considered for a
duration of up to 14 or 35 days, for total knee or
hip arthroplasty, respectively.334–337
IIa A
NOACs in thromboprophylaxis dose may be
considered as alternative treatments to LMWH
after total knee and hip arthroplasty.333
IIb A
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LMWH, low molecular weight heparin; NCS, non-cardiac surgery; NOAC, non-vitamin
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aClass of recommendation.
bLevel of evidence.
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of serious adverse events, major cardiac and cerebrovascular events,
allogenic blood transfusion requirements, and length of stay were in-
creased in patients with ID.
Based on the possibility of preserving the patients’ own blood
resources and to enable safe handling of donor blood, the
World Health Assembly (WHA) has endorsed the Patient
Blood Management (PBM) approach (WHA63.12). Patient Blood
Management is a patient-centred and multidisciplinary approach to
manage anaemia, minimize iatrogenic blood loss and bleeding, and
harness tolerance to anaemia in an effort to improve patient out-
come.350–355 A comprehensive PBM programme addressing all three
PBM pillars was associated with reduced transfusion need of RBC
units, and lower complication and mortality rates.350
5.5.1. Pre-operative anaemia—diagnosis and
treatment
A serum ferritin level,30 ng/mL, transferrin saturation,20%, and/
or microcytic hypochromic red cells (mean corpuscular volume
,80 fl, mean corpuscular haemoglobin ,27 g/dL) are indicative of
ID. In the presence of inflammation or transferrin saturation
,20%, a ferritin level of ,100 ng/mL points to functional ID (iron
sequestration) (Table 10).
Apart from compromised bone marrow function, most types of
anaemia are correctable within a period of 2–4 weeks. Oral and
i.v. iron therapy can be used to treat ID. Intravenous iron products
consist of an iron core embedded in a carbohydrate shell, which in-
fluences the stability of the drug, for example: iron sucrose com-
prises a less stable shell, allowing a maximum dose of 200 mg per
infusion, whereas ferric carboxymaltose, ferric derisomaltose, and
ferumoxytol have a stable shell associated with slow iron release
and allowing a higher dose. Administration of i.v. iron has been
shown to effectively reverse anaemia in ID patients.356,357
Intravenous iron is efficacious and safe359 and should be used in
patients in whom oral iron is not tolerated, or if surgery is planned
in short notice after the diagnosis of ID. A prospective observational
study of 1728 major surgical patients showed that the prevalence of
ID was 50%, 46.3%, and 52.7% in patients with haemoglobin ,8.0,
8.0–8.9, and 9.0–9.9 g/dL, respectively.357 Furthermore, all iron sup-
plemented iron-deficient anaemic patients required fewer RBC
transfusions during the post-operative period, and a reduced
intra-operative transfusion rate was observed if iron was supplemen-
ted .7 days before surgery. In addition, the length of stay was
significantly reduced by 2.8 days for iron supplemented patients. In
the recent PREVENTT trial studying patients with anaemia undergo-
ing major abdominal surgery, pre-operative iron transfusion failed to
improve outcomes;360 however, due to a fault in the study design, all
anaemic patients received i.v. iron but not all (50–70%) were suf-
fering from ID.
Recombinant human erythropoietin (rHuEPO) has frequently
been used together with iron supplementation to increase pre-
operative haemoglobin concentrations. A recent Cochrane review
found that the administration of rHuEPO+ iron to anaemic patients
prior to NCS, compared with control treatment, reduced the need
for RBC transfusion and increased the haemoglobin concentration
pre-operatively; however, there were no important differences in
the risk of adverse events or mortality within 30 days, or in length
of hospital stay.361Well-designed, adequately powered RCTs are re-
quired to more precisely estimate the impact of this combined
treatment.
Pre-operative management of patients with anaemia can be simpli-
fied by making use of standard operating procedures or algorithms in
which thresholds for diagnosis and treatment are depicted.362 An ex-
ample of such an algorithm can be found in the PBM programme363
(see Supplementary data, Figure S4) and in the British Committee for
Standards in Haematology (BCSH) Guidelines on the Identification
and Management of Pre-Operative Anaemia.364
5.5.2. Bleeding and reduction of iatrogenic
diagnostic/surgery-related blood loss
Blood loss associated with laboratory testing can either cause or ag-
gravate hospital-acquired anaemia, which is associated with in-
creased length of stay and complications. In 1867 patients
undergoing cardiac surgery, an average of 115 tests per patient
were performed, with a cumulative median volume of 454 mL.365
A reduction in blood drawn for laboratory analyses can be achieved
by lowering the frequency of sampling and using paediatric-size col-
lection tube sizes, for example. To decrease blood loss, blood-saving
bundles could be used (e.g. a closed-loop arterial blood sampling sys-
tem, smaller sampling tubes, reduction of frequency of blood
Table 10 Laboratory parameters for the diagnosis of
absolute iron-deficiency anaemia
Parameter Normal Iron deficiency
Mean corpuscular haemoglobin (g/dL) 28–33 ,27
Mean cellular volume (fL) 80–96 ,80
Transferrin saturation (%) 16–45 ,20
Ferritin (ng/mL) 18–360 ,30a
Reticulocytes haemoglobin (ng/mL) 18–360 ,30 ©
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aIn cases of chronic kidney disease, chronic heart failure or infections, iron deficiency is
diagnosed with ferritin level ,100 ng/mL or transferrin saturation ,20%.358
Recommendation Table 16— Recommendations for
intra- and post-operative complications associated
with anaemia
Recommendations Classa Levelb
It is recommended to measure haemoglobin
pre-operatively in patients scheduled for
intermediate- to high-risk NCS.350,354
I B
It is recommended to treat anaemia in advance of
NCS, in order to reduce the need for RBC
transfusion during NCS.357,361
I A
The use of an algorithm to diagnose and treat
anaemic patients before NCS should be
considered.
IIa C
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NCS, non-cardiac surgery; RBC, red blood cell.
aClass of recommendation.
bLevel of evidence.
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drawings, and sample numbers). Such a strategy decreased mean
blood loss per intensive care unit (ICU) day from 43.3 mL to
15.0 mL (P, 0.001),366 mainly due to the introduction of
closed-loop arterial blood sampling systems. In addition, units of
transfused RBCs per 100 observation days decreased from 7 to
2.3 (P, 0.001).366
A reduction in surgery-related blood loss starts from the pre-
operative stage, with appropriate cessation strategies for anticoagu-
lation and antiplatelet therapy. Intra-operative approaches to avoid
blood loss include: (i) advanced anaesthetic; (ii) advanced surgical
techniques with meticulous haemostasis, such as minimally invasive
surgery and laparoscopic surgery; (iii) judicious use of diathermy dis-
section; (iv) physician’s mindfulness regarding limiting blood loss; and
(v) application of topical haemostatic agents.367–369
Adequate coagulation management to minimize blood loss needs
to be a pre-condition before RBC transfusion is considered. In this
respect, the use of a coagulation algorithm is recommended,370,371
encompassing pre-operative assessment,372 and ensuring basic con-
ditions for haemostasis, reversal of anticoagulants, point-of-care
diagnostics in bleeding patients, and optimized coagulation manage-
ment with the use of clotting factor concentrates.373,374
Tranexamic acid is an antifibrinolytic agent that is widely used for
prophylaxis and treatment of bleeding caused by hyperfibrinolysis. A
meta-analysis including 129 trials encompassing more than 10 000
patients to assess the effect of tranexamic acid on blood transfusion
showed that administration of tranexamic acid reduced allogeneic
blood transfusion by 38% (P, 0.001).375 In the recent POISE-3
study, 9535 patients undergoing NCS were randomized to tranex-
amic acid (1 g i.v. bolus) or placebo at the start and end of surgery.
The incidence of the primary efficacy outcome (composite bleeding
outcome) at 30 days was significantly lower with tranexamic acid
than with placebo (HR, 0.76; 95% CI, 0.67–0.87).376 With respect
to the primary safety outcome (composite CV outcome), the results
did not meet the non-inferiority criteria (HR, 1.02; 95% CI,
0.92–1.14; P= 0.04 for non-inferiority).
The use of (washed) cell recovery is highly recommended in sur-
gical settings where blood loss is routinely or anticipated to be
.500 mL, as it reduces the rate of exposure to allogeneic RBCs,
risk of infection, and length of stay. A meta-analysis including 47 trials
encompassing 3433 patients of all surgical disciplines showed that the
use of washed cell salvage reduced the rate of exposure to allogeneic
RBC transfusion by 39% (P, 0.001), risk of infection by 28% (P=
0.03), and length of stay by 2.31 days (P, 0.001).377
5.5.3. Optimal blood component use with
patient-centred clinical decision support
In order to optimize utilization of allogeneic blood products and to
ensure guideline-adherent transfusion strategies, computerized
physician order-entry systems should be considered.390,391 For ex-
ample, Kaserer and colleagues evaluated the effectiveness of a mon-
itoring and feedback programme and compared transfusion rates of
.210 000 patients before and after implementation;392 overall,
transfusion of RBCs was reduced by 40%.
Informed consent should be obtained from patients prior to trans-
fusion of allogeneic blood products. It is necessary to effectively com-
municate the risks and benefits of the various potential interventions
to the patient. It may further be recommended that any transfusion
of allogeneic blood products should be mentioned in the discharge
summary. In addition, the patient’s own preferences and values
should be considered when developing a medical plan.
6. Specific diseases
Patients with CVD have an increased risk of peri-operative CV com-
plications.45 Both the risk of complications and the peri-operative
management depend on the specific type of CVD.
6.1. Coronary artery disease
6.1.1. Risk for patients with coronary artery disease
The peri-operative risk of CV complications for patients with estab-
lished CAD depends on the baseline CV risk, type of surgery, and
Recommendation Table 17— Recommendations for
intra- and post-operative complications associated
with blood loss
Recommendations Classa Levelb
In patients undergoing surgery with expected
blood loss of ≥500 mL, use of washed cell salvage
is recommended.377,378
I A
It is recommended to use point-of-care
diagnostics for guidance of blood component
therapy, when available.370,379–383
I A
Continued
In patients undergoing NCS and experiencing
major bleeding, administration of tranexamic acid
should be immediately considered.375,376,384–386
IIa A
Use of closed-loop arterial blood sampling
systems should be considered to avoid blood
loss.366,378,387,388
IIa B
Application of meticulous haemostasis should be
considered a routine procedure.350,389
IIa B
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NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
Recommendation Table 18— Recommendations for
intra- and post-operative complications associated
with allogeneic blood transfusion
Recommendations Classa Levelb
A feedback/monitoring programme or clinical
decision support system should be considered to
be assessed before blood transfusion.392–396
IIa B
Before allogenic blood transfusion, it should be
considered to obtain an extensive consent about
risks asssociated with transfusion.
IIa C
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aClass of recommendation.
bLevel of evidence.
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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 influ-
ence 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 per-
formed without further delay and the time for pre-operative assess-
ment is limited.
In patients scheduled for elective NCS who present with an ACS,
the management of ACS should follow the guidelines for ACS pa-
tients 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 manage-
ment (e.g. type of surgery, anaesthesia, medical therapy, and peri-
operative monitoring) should be considered.
In patients with known CAD, it is recommended to collect infor-
mation regarding previous invasive and non-invasive diagnostic ex-
aminations, and therapeutic interventions for CAD, within a
sufficient time interval before the NCS, ideally at the time the pro-
posal 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 strat-
egy in patients with CCS. The process of decision-making related to
revascularization in CCS should be individualized, in order to priori-
tize revascularization in case of involvement of a significant amount of
ischaemic myocardium or refractory symptoms, while medical man-
agement 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 pre-
vent 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) re-
duced the risk of peri-operative mortality and MI in patients under-
going 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 be-
fore 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 CCSwere randomized to either optimal med-
ical therapy or coronary revascularization (surgical or percutaneous)
before major vascular surgery.399 In this study, patients receiving cor-
onary 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%, re-
spectively). 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 revascular-
ization 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 subse-
quent meta-analysis including 3949 patients showed no clinical bene-
fit 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 revasculari-
zation before surgery. However, in patients receiving coronary re-
vascularization, 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 revascular-
ization 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 angiog-
raphy if medical therapy failed.402 This trial did not find a significant
difference in the primary composite end-point of death and MI be-
tween treatment groups. Interestingly, these neutral results were in-
applicable 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 revasculariza-
tion and the 2019 ESC Guidelines for the diagnosis and manage-
ment 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 revascular-
ization in ACS patients scheduled for NCS. High- and very high-risk
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patients should be treated according to the 2020 ESC Guidelines for
the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation,98 with an early (,24 h) or
immediate (,2 h) invasive strategy, respectively. In low-risk groups
amenable to a selective invasive strategy, the decision-making should
be consistent with the approach for CCS patients.
In a post hoc analyses of the HIP-ATTACK (HIP Fracture
Accelerated Surgical TreaTment And Care tracK) trial, patients
Optimize guideline-recommended
medical therapy
(Class I )
Optimize guideline-recommended
medical therapy
(Class I )
Diagnostic and therapeutic pathways
according to ACS Guidelines and 
individual basis
(Class I)
Cardiologist–surgeon–anaesthesist
discussion regarding myocardial
revascularization options and
antithrombotic strategy dependent
on the options and acceptable
time interval to postpone NCS
Low-risk NCS
No further screening
Intermediate-risk NCS
Clinical examination + ECG
+ biomarkersa (Class I)
Symptoms or abnormal ECG
or poor exercise tolerance
or elevated biomarkers
Elevated hs-troponin or
stress-induced ischaemia
High-risk NCS
Functional capacityb (Class IIa)
Clinical examination + ECG
+ biomarkersa (Class I)
Functional capacityb (Class IIa)
± TTE ± stress imaging
± TTE ± stress imaging
ICAc ± iwFR/FFR
Symptoms or abnormal ECG
or poor exercise tolerance
or elevated biomarkers
N
N
N
Y
Y
CCSACS
Management of  patients with ACS or CCS scheduled for NCS
Y
Figure 12Management of patients with acute or chronic coronary syndrome scheduled for non-cardiac surgery. ACS, acute coronary syndrome; BNP,
B-type natriuretic peptide; CABG, coronary artery bypass graft; CAD, coronary artery disease; CCS, chronic coronary syndrome; ECG, electrocardio-
gram; FFR, fractional flow reserve; hs-cTn, high-sensitivity cardiac troponin; ICA, invasive coronary angiography; iwFR, instantaneous wave-free ratio;
N, no; NCS, non-cardiac surgery; NT-proBNP, N-terminal proBNP; PCI, percutaneous coronary intervention; TTE, transthoracic echocardiography.
Y, yes; The figure provides a schematic representation of diagnostic tools and therapy to be implemented according to surgical risk and underlying cardiac
condition. aBiomarkers: hs-cTn T/I (Class I)+ BNP/NT-proBNP (Class IIa). bFunctional capacity based on Duke Activity Status Index (DASI) or the ability
to climb two flights of stairs. cICA+ PCI/CABG on a case-by-case basis according to the Heart Team.
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with increased baseline troponin before randomization showed
lower risk of mortality with accelerated surgery (within 6 h
from the diagnosis) vs. standard of care (HR, 0.38; 95% CI,
0.21–0.66).57
The selection of the type of revascularization (PCI or CABG)
should be based on the coronary anatomy and complexity of ath-
erosclerosis, and the presence of diabetes.268,404 When PCI is cho-
sen, the use of a DES is recommended.407 In case of a
life-threatening clinical condition requiring undeferrable NCS and
concomitant ACS-STEMI with an indication for coronary revascu-
larization, a minimalistic approach with plain balloon angioplasty
and delayed stenting might be considered.408,409 Figure 12 shows
a summary of diagnostic and therapeutic pathways in patients
with CAD scheduled for NCS.
6.2. Chronic heart failure
6.2.1. Risk for patients with heart failure
Heart failure is an established risk factor for post-operative mortality
across a broad range of surgical specialties.410–412 Several tools for
risk calculations in patients undergoing NCS include HF as a predict-
or of adverse post-operative events.411,413
The risk of adverse post-operative events associated with HF de-
pends on whether the LV systolic function is preserved or reduced,
on the haemodynamic compensation, and on the presence of symp-
toms.414,415 In patients undergoing NCS, there is a risk of acute de-
compensated HF, with rapid onset or worsening of symptoms and/
or signs of HF, precipitated by fluid accumulation and/or comorbid
conditions.412
Patients with peri-operative acute or chronic HF are at increased
risk of mortality during NCS. In a recently published analysis of 21
560 996 hospitalizations for NCS, the presence of any diagnosis of
HF was associated with significantly higher in-hospital all-cause mor-
tality compared with absence of HF (4.8% vs. 0.78%; adjusted OR,
2.15; 95% CI, 2.09–2.22).416 Among patients with a chronic HF diag-
nosis, peri-operative mortality was greater in those with acute ex-
acerbation of chronic HF compared to those with compensated
chronic HF. In a recent large-scale cohort study of individuals under-
going ambulatory surgery, the crude 90 day mortality was 2.0%
among patients with HF and 0.4% among patients without HF.417
The crude risk of 30 day post-operative complications was 5.7%
and 2.7%, respectively. Of note, the risk of mortality progressively in-
creased with decreasing systolic function. It is not recommended to
perform elective NCS in patients with decompensated HF.
The value of pre-operative assessment of LV function with
TTE and measurement of natriuretic peptides (BNP or
NT-proBNP) is discussed in Section 4.4. The TTE should not be older
than 6 months, or performed just before NCS in the case of clinical
worsening.
6.2.2. Pre- and post-operative management
strategies
In order to reduce the risk of acute decompensation and the risk of
mortality, optimal guideline-directed medical treatment of HF before
scheduled NCS is recommended.412 Special attention should be gi-
ven to the fluid balance, since high-volume infusion is often needed
in the peri-operative period. Invasive monitoring of the arterial
pressure aiming to obtain oximetric and metabolic parameters
during NCS is frequently needed for intermediate- to high-risk
NCS among HF patients. Furthermore, dynamic variables derived
from the arterial pressure waveform (cardiac output, pulse
pressure variation, stroke volume variation) are useful for guiding
protocolled goal-directed therapy. Use of more invasive tools,
such as right heart catheterization or transoesophageal echocardiog-
raphy (TEE), might be considered on an individual patient level (see
Section 7.1).
Baseline medication should be continued throughout the peri-
operative period, in accordance with the recommendations pro-
vided in Section 5.2. It is recommended to perform ECG, measure
biomarkers of myocardial injury (cTn T/I), and perform echocardiog-
raphy to tailor the optimal treatment strategy in patients with acute
decompensated HF post-operatively.
Recommendation Table 19— Recommendations for
the timing of non-cardiac surgery and revasculariza-
tion in patients with known coronary artery disease
Recommendations Classa Levelb
Patients with CCS
If PCI is indicated before NCS, the use of
new-generation DES is recommended over BMS
and balloon angioplasty.268
I A
Pre-operative evaluation of patients with an
indication for PCI by an expert team (surgeon and
cardiologist) should be considered before elective
NCS.
IIa C
Myocardial revascularization before high-risk
elective NCS may be considered, depending on
the amount of ischaemic myocardium, refractory
symptoms, and findings at coronary angiography
(as in the case of left main disease).399,402,403
IIb B
Routine myocardial revascularization before low-
and intermediate-risk NCS in patients with CCS is
not recommended.399,400
III B
Patients with ACS
If NCS can safely be postponed (e.g. at least 3
months), it is recommended that patients with
ACS being scheduled for NCS undergo diagnostic
and therapeutic interventions as recommended
for ACS patients in general.98,268
I A
In the unlikely combination of a life-threatening
clinical condition requiring urgent NCS, and
NSTE-ACS with an indication for
revascularization, the priorities for surgery on a
case-by-case basis should be considered by the
expert team.268
IIa C
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ACS, acute coronary syndrome; BMS, bare metal stent; CAD, coronary artery disease;
CCS, chronic coronary syndrome; DES, drug-eluting stent; NCS, non-cardiac surgery;
NSTE-ACS, non-ST-segment elevation acute coronary syndrome; PCI, percutaneous
coronary intervention.
aClass of recommendation.
bLevel of evidence.
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The management of patients with cardiac implantable electronic
devices (CIEDs) undergoing NCS is discussed in Section 6.4.5.
In patients with resynchronization devices (cardiac resynchroniza-
tion therapy [CRT]), it is recommended to keep the device on to
provide better haemodynamic stability.
6.2.3. Hypertrophic obstructive cardiomyopathy
Patients with hypertrophic cardiomyopathy with LV outflow tract
obstruction (HOCM) have an increased risk of complications dur-
ing NCS and require additional attention.418 It is recommended to
perform TTE before NCS in order to determine the extent of the
hypertrophy, obstruction, and diastolic function.419 Avoidance of
prolonged pre-operative fasting and dehydration is important to
maintain stroke volume and reduce the risk of increased obstruc-
tion. Furthermore, it is important to avoid vasodilating anaesthetic
agents and maintain neutral fluid balance during the peri-operative
period. The heart rate should be kept low (60–65 beats per
minute [b.p.m.]) and AF should be avoided. Medication used
to treat LV outflow tract obstruction should remain on board
during NCS.
6.2.4. Patients with ventricular assist devices
undergoing non-cardiac surgery
Ventricular assist devices (VADs) play an important role in the treat-
ment of patients with end-stage HF who require a bridge to heart
transplantation or as a permanent destination therapy. As the num-
ber of patients receiving VAD as destination therapy increases,420,421
the need for NCS in this specific subset of patients is expected to in-
crease in years to come. Non-cardiac surgery should be performed
in surgical centres that have access to VAD teams (Table 11).
6.3. Valvular heart disease
6.3.1. Risk for patients with valvular heart disease
Valvular heart disease increases the risk of peri-operative CV
complications during NCS. The magnitude of risk is highly
Table 11 Peri-operative approach to patients with ventricular assist devices undergoing non-cardiac surgery
Pre-operative Intra-operative Post-operative
• Multidisciplinary team identified (primary
surgical and anaesthesia teams, cardiac surgery,
HF cardiologist, VAD personnel)
• Pre-operative medical optimization when
possible or necessary
• Physical examination focused on the sequelae
of HF
• Baseline ECG, echocardiogram, and laboratory
values
• Manage pacemaker/ICD settings when indicated
• CT examination to evaluate possible driveline
interference with the operative field
• Hold, bridge, or reverse anticoagulation when
indicated, after VAD team consultation
• Standard American Society of Anesthesiologists monitors
• Cerebral tissue oxygenation, processed
electroencephalogram, arterial line with ultrasound guidance,
central venous catheter if fluid shifts are expected, PA catheter
only if severe pulmonary hypertension, TEE available
• Monitor VAD control console
• External defibrillator pads in place
• Optimize pre-load, support RV function, avoid increase in
afterload
• Gradual peritoneal insufflations and position changes
• Standard post-anaesthesia care
unit unless ICU is otherwise
indicated
• Extubation criteria are
unchanged
• Avoid hypoventilation, optimize
oxygenation
• Resume heparin infusion when
post-op bleeding risk is
acceptable
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CT, computed tomography; ECG, electrocardiogram; HF, heart failure; ICU, intensive care unit; PA, pulmonary artery; RV, right ventricular; TEE, transoesophageal echocardiography;
VAD, ventricular assist device.
Adapted from Roberts et al.421
Recommendation Table 20— Recommendations for
management of heart failure in patients undergoing
non-cardiac surgery
Recommendations Classa Levelb
In patients with suspected or knownHF scheduled
for high-risk NCS, it is recommended to evaluate
LV function with echocardiography and
measurement of NT-proBNP/BNP levels, unless
this has recently been performed.112,113,422,423
I B
It is recommended that patients with HF
undergoing NCS receive optimal medical
treatment according to current ESC
guidelines.412
I A
In patients with HF undergoing NCS, it is
recommended to regularly assess volume status
and signs of organ perfusion.
I C
A multidisciplinary team including VAD specialists
is recommended for peri-operative management
of patients with HF receiving mechanical
circulatory support.
I C
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BNP, B-type natriuretic peptide; ESC, European Society of Cardiology; HF, heart failure;
LV, left ventricular; MCS, mechanical circulatory support; NCS, non-cardiac surgery;
NT-proBNP, N-terminal pro-B-type natriuretic peptide; VAD, ventricular assist device.
aClass of recommendation.
bLevel of evidence.
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variable and depends on the severity of VHD and type of NCS.
It is particularly increased in patients with obstructive valve
pathology, for example symptomatic AS or MS, where peri-
operative volume shifts and arrhythmia may lead to rapid
decompensation.424
6.3.2. Pre-operative management strategies and
risk-reduction strategy
Clinical and echocardiographic evaluation is recommended in all pa-
tients with known or suspected VHDwho are scheduled for elective
intermediate-or-high-risk NCS. Patients in whom mild-to-moderate
VHD was diagnosed .1 year earlier should have clinical and echo-
cardiographic re-assessment. Heart team discussion may be helpful
in patients with significant VHD. The risks of valvular intervention
and the risk of NCS-related complications should be estimated
and communicated to the patient and the surgical team.
6.3.2.1. Aortic valve stenosis
The peri-operative risk associated with AS during NCS depends
upon the presence of symptoms, stenosis severity, and coexisting
cardiac disease (e.g. CAD, mitral insufficiency, or reduced LVEF).
Severe symptomatic AS is a significant risk factor for post-operative
MI and HF, and a predictor for 30 day and long-term mortality after
NCS.425,426 Careful peri-operative management is essential in pa-
tients undergoing intermediate- and high-risk NCS, albeit the signifi-
cance of AS in patients undergoing low-risk NCS might have been
overemphasized in studies that pre-date the more recent advances
in anaesthesia, surgical techniques, and post-operative management.
Clinical examination + ECG + biomarkers + TTE ± TEE
(Class I)
Optimal guideline-recommended medical treatmenta
(Class I)
Low-risk NCS
Patient risk for valve procedures
AND
AND
Intermediate or high-risk NCS
Patient risk for valve procedures
Low High
Low High
Low- or intermediate-risk NCS
High-risk NCS
Patient risk for valve procedures
Low High
Management of patients with severe aortic valve stenosis scheduled for elective or time-sensitive NCS
Multidisciplinary consultation
Symptoms
Individual decision about
necessity of valve
procedure before NCS
NCS without
additional procedures
Heart Team
(TAVI or SAVR)
(Class I)
Consider BAV before
NCS if feasible, or NCS
under strict monitoring
(Class IIb)
NCS without additional procedures
Heart Team
(TAVI or SAVR)
(Class IIa)
Consider BAV before
NCS if feasible, or NCS
under strict monitoring
(Class IIb)
LV-dysfunction (LVEF <50%)
NCS without
additional
procedures
Y
Y
N N
Figure 13 Management of patients with severe aortic valve stenosis scheduled for non-cardiac surgery. BAV, balloon aortic valvuloplasty; ECG, elec-
trocardiogram; LV, left ventricular; LVEF, left ventricular ejection fraction; N, no; NCS, non-cardiac surgery; SAVR, surgical aortic valve replacement; TAVI,
transcatheter aortic valve implantation; TTE, transthoracic echocardiography; TEE, transoesophageal echocardiography. Y, yes; The figure provides a
schematic representation of diagnostic assessment or therapy to be implemented according to surgical risk and underlying cardiac condition. aThis applies
to treatment of complications (e.g. atrial fibrillation, heart failure). No medical therapy is recommended for aortic stenosis per se.
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Aortic valve replacement has been associated with reduced in-hospital
and 30 day mortality and morbidity among patients with AS undergo-
ing intermediate- to high-risk NCS.425,426 However, the decision re-
garding the timing of AVR in relation to NCS should be weighted
according to the baseline risk profile and the risk associated with the
NCS. The choice of surgical aortic valve replacement (SAVR) vs.
TAVI should follow the 2021 ESC/EACTS Guidelines for the manage-
ment of valvular heart disease245 and patient’s informed preference
(Figure 13).
In patients with severe symptomatic AS, in whom NCS can be de-
ferred, aortic valve intervention (SAVR or TAVI) is recommended
before NCS. In patients requiring time-sensitive NCS, TAVI is a rea-
sonable option.427 In patients with severe symptomatic AS in need of
time-sensitive NCS in whom TAVI or SAVR are unfeasible, balloon
aortic valvuloplasty (BAV) may be considered before NCS as a bridge
to definitive aortic valve repair. Asymptomatic patients with severe
AS and normal LVEF can safely undergo low- to intermediate-risk
NCS, unless the NCS is associated with large volume shifts.245,428
6.3.2.2. Mitral valve stenosis
Non-cardiac surgery can be performed with a relatively low risk of
complications in patients with mild MS (valve area .1.5 cm2) and
in asymptomatic patients with moderate-to-severe MS (valve area
≤1.5 cm2) and systolic pulmonary artery pressure (SPAP)
,50 mmHg on echocardiography.429 As transmitral gradients are
flow-sensitive, tachycardia and fluid overload can cause pulmonary
oedema during NCS. In this regard, arterial vasodilators should be
avoided and surveillance for peri-operative AF is of paramount im-
portance. Management of anticoagulation for patients with high
thrombotic risk is discussed in Section 5.3.2. In asymptomatic patients
with moderate-to-severe MS and SPAP .50 mmHg, and in symp-
tomatic patients, the peri-operative risk of CV events is increased.
Intermediate-risk or high-risk NCS
Low-risk NCS
Management of severe secondary mitral valve regurgitation in patients scheduled for NCS
Clinical examination + ECG + biomarkers + TTE ± TEE (Class I)
Persistent symptoms despite GDMT
Elective NCS
Optimal GDMT including
CRT if indicated
(Class I)
± Myocardial
revascularizationa
Optimal GDMT
(Class I)
Time-sensitive NCS
No additional procedures
Consider NCS under strict monitoring
Inoperable or at high procedural risk
TEER or surgery (repair when possible) depending
on eligibility and according to the decision of the
Heart Team
(Class IIa)
Y
Y
Y
N
N
AND AND
Multidisciplinary
consultation
NCS
under strict monitoring
AND
Figure 14 Management of patients with secondary mitral valve regurgitation scheduled for non-cardiac surgery. ECG, electrocardiogram; GDMT,
guideline-directed medical therapy; N, no; NCS, non-cardiac surgery; TTE, transthoracic echocardiography; TEE, transoesophageal echocardiography;
TEER, transcatheter edge-to-edge repair. Y, yes; aCoronary angiography+ PCI/CABG on a case-by-case according to the expert team.
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In this case, a percutaneous mitral commissurotomy (PMC) should
be considered before high-risk NCS. Otherwise, a multidisciplinary
team should manage patients with moderate-to-severe MS who
are ineligible for PMC, and NCS should be performed only if neces-
sary. Intermediate-risk NCS may be performed in asymptomatic pa-
tients with severe MS with appropriate intra-operative and
post-operative haemodynamic monitoring, if valve morphology is un-
suitable for PMC.
6.3.2.3. Aortic valve regurgitation
In patients with mild-to-moderate aortic valve regurgitation (AR),
NCS can be performed without additional risk. Patients with severe
AR in whom valvular intervention is needed should be treated be-
fore intermediate-or-high-risk elective NCS (see Recommendation
Table 21 and the 2021 ESC/EACTS Guidelines for the management
of valvular heart disease).245
6.3.2.4. Mitral valve regurgitation
In patients with severe symptomatic mitral valve regurgitation (MR),
the type of valve disease (primary or secondary) and LV function
should be assessed. Patients with secondary MR, especially of
ischaemic aetiology, are at increased risk of CV complications
during NCS.430 Patients with severe symptomatic MR fulfilling the
intervention criteria should be referred for valve treatment
before intermediate- or high-risk elective NCS. In case of
symptomatic moderate-to-severe secondary MR, patients meeting
the Cardiovascular Outcomes Assessment of the MitraClip
Percutaneous Therapy for Heart Failure Patients With Functional
Mitral Regurgitation (COAPT) criteria should be considered
for transcatheter edge-to-edge treatment before NCS
(Figure 14).245,431 In patients with severe primary MR with symptoms
or asymptomatic with LV dysfunction, valve repair is the recom-
mended therapy (see Recommendation Table 21 and the 2021 ESC/
EACTS Guidelines for the management of valvular heart disease245).
In patients with reduced LVEF and concomitant AR or MR,
intra-operative haemodynamic monitoring, heart rate control, and
careful fluid balance are crucial to avoid haemodynamic deterior-
ation, especially during high-risk surgery.
6.3.2.5. Patients with prosthetic valve(s)
Patients who have undergone previous surgical correction of VHD
and have a prosthetic valve can undergo NCS provided that there
is no evidence of valve dysfunction. In current practice, the main
problem is the need for a modification of the anticoagulation regimen
in the peri-operative period; this is discussed in detail in Section 5.3.
6.3.2.6. Prophylaxis of infective endocarditis
Prophylaxis against infective endocarditis in patients requiring NCS
should be consistent with the 2015 ESC Guidelines for the manage-
ment of infective endocarditis.432
Recommendation Table 21— Recommendations for
management of valvular heart disease in patients
undergoing non-cardiac surgery
Recommendations Classa Levelb
Clinical and echocardiographic evaluation (if not
recently performed) is recommended in all
patients with known or suspected VHD who are
scheduled for elective intermediate- or high-risk
NCS.
I C
Aortic valve stenosis
AVR (SAVR or TAVI) is recommended in
symptomatic patients with severe AS who are
scheduled for elective intermediate- or high-risk
NCS.
I C
Continued
In asymptomatic patients with severe AS who are
scheduled for elective high-risk NCS, AVR (SAVR
or TAVI) should be considered after Heart Team
discussion.
IIa C
In patients with severe symptomatic AS in need of
time-sensitive NCS or in whom the TAVI and
SAVR are unfeasible, BAV may be considered
before NCS as a bridge to definitive aortic valve
repair.
IIb C
Aortic valve regurgitation
In patients with symptomatic severe AR or
asymptomatic severe AR and LVESD.50 mm or
LVESDi (LVESD/BSA) .25 mm/m2 (in patients
with small body size) or resting LVEF ≤50%, valve
surgery is recommended prior to elective
intermediate- or high-risk NCS.
I C
Mitral valve stenosis
In patients with moderate-to-severe rheumatic
MS and symptoms or SPAP .50 mmHg, valve
intervention (PMC or surgery) is recommended
before elective intermediate- or high-risk NCS.
I C
Mitral valve regurgitation
In patients with symptomatic severe primary MR
or asymptomatic severe primary MR with LV
dysfunction (LVESD ≥40 mm and/or LVEF
≤60%), valve intervention (surgical or
transcatheter) should be considered prior to
intermediate- or high-risk NCS, if time allows.
IIa C
In patients with severe secondary MR who remain
symptomatic despite guideline-directed medical
therapy (including CRT if indicated), valve
intervention (transcatheter or surgical) should be
considered beforeNCS, in eligible patients with an
acceptable procedural risk.
IIa C
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AS, aortic valve stenosis; AR, aortic valve regurgitation; AVR, aortic valve replacement;
BAV, balloon aortic valvuloplasty; BSA, body surface area; CRT, cardiac
resynchronization therapy; LV, left ventricular; LVEF, left ventricular ejection fraction;
LVESD, left ventricular end-systolic diameter; LVESDi, left ventricular end-systolic
dimension index; MR, mitral valve regurgitation; MS, mitral stenosis; NCS, non-cardiac
surgery; PMC, percutaneous mitral commissurotomy; SAVR, surgical aortic valve
replacement; SPAP, systolic pulmonary artery pressure; TAVI, transcatheter aortic
valve implantation; VHD, valvular heart disease.
aClass of recommendation.
bLevel of evidence.
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6.4. Known or newly diagnosed
arrhythmias
Arrhythmias pose a significant burden to patients undergoing NCS,
contributing to excessive morbidity and mortality.433,434
6.4.1. Peri-operative management—general
measures
Arrhythmias—namely, supraventricular tachycardia (SVT) and ven-
tricular tachycardia (VT)—may accompany acute surgical illness, but
should not defer urgent surgical procedures, unless the arrhythmia
is life-threatening. All patients with known arrhythmia undergoing
elective surgery should have a 12-lead ECG performed pre-
operatively and undergo a cardiology check-up. Prevention of poten-
tial arrhythmic triggers is crucial: electrolyte and acid-base imbalance,
myocardial ischaemia (also caused by excessive blood loss and an-
aemia), and large volume shifts, which can provoke subsequent auto-
nomic hyperactivity, should be avoided in the pre-, intra-, and
post-operative periods. Patients with a systolic HF should receive op-
timal treatment, as such therapy reduces the risk of total mortality
and sudden cardiac death (SCD).435 Patients already taking AADs
should generally not stop taking these drugs. Patients at high-risk of
malignant arrhythmias should have continuous ECG monitoring
through the whole peri-operative period, with particular emphasis
placed on patients who have had implantable cardioverter–defibrilla-
tors (ICDs) deactivated during NCS.
6.4.2. Supraventricular arrhythmias
Supraventricular arrhythmias do not usually cause deferral of sur-
gery. In rare cases, presence of pre-excitation and AF conducted rap-
idly over an accessory pathway flag a patient at risk of SCD and may
indicate the need for ablation, if surgery is not emergent.
Supraventricular premature beats usually do not require therapy.
Identification and correction of potential triggers (electrolyte and
acid-base imbalance, volume overload, etc.) are highly recom-
mended. Peri-operative SVT typically responds well to vagal man-
oeuvres, or to a bolus of adenosine if unsuccessful. If SVT persists
or reoccurs, i.v. beta-blockers, verapamil, or diltiazem can be used
for rhythm conversion or temporal slowing of atrioventricular con-
duction.436 Prompt cardioversion should be performed in rare cases
of haemodynamically unstable SVT. If prophylactic therapy is needed
to prevent recurrent SVT, beta-blockers or non-dihydropyridine
CCBs (verapamil, diltiazem) can be used, and flecainide/propafenone
or amiodarone can be considered if ineffective. Rarely, when SVT
recurs despite therapy or becomes incessant, ablation should be
considered in patients undergoing high-risk, non-emergent sur-
gery. Recently published results of an RCT confirmed the superior-
ity of radiofrequency (RF) ablation over AADs for persistent
atrioventricular nodal re-entry tachycardia. Large registries and
meta-analyses have demonstrated efficacy and safety of RF abla-
tion in WPW syndrome and other SVTs, with a single-procedure
success rate of .90.437–441
6.4.3. Atrial fibrillation/flutter
The majority of patients with AF receive lifelong OAC therapy for
the prevention of stroke and systemic embolism,99 and the peri-
operative management of OAC therapy will depend on the type
of surgery (see Section 5.3.2).99,240 Sometimes AF is asymptomatic442
and may be first detected on admission for surgery, or may first occur
in the pre-operative period. The initial management of newly diagnosed
AF includes prevention of thromboembolism, and symptom control,
and should not be deferred awaiting consultation with a cardiologist.99
In patients with newly diagnosed AF who require systemic OAC ther-
apy for stroke prevention, the choice of anticoagulant in the pre-
operative period depends on the type of surgery (see Section 5.3.2).
Optimal rate control (i.e. resting heart rate ,110 b.p.m.)99 is manda-
tory in all patients with AF, whereas rhythm control (i.e. achieving
and maintenance of sinus rhythm) in the pre-operative period may
be considered only if symptoms persist despite optimal rate control.
Rate control can be achieved using beta-blockers or non-
dihydropyridine CCBs (verapamil, diltiazem). Amiodarone can be
used as first-line therapy in patients with HF, whereas digoxin is usu-
ally ineffective in high adrenergic conditions such as surgery.
Pharmacological cardioversion of symptomatic recent-onset AF
can be attempted using flecainide or propafenone; in patients with-
out significant LV hypertrophy, LV systolic dysfunction, or IHD,
the use of flecainide or propafenone results in prompt (3–5 h) and
safe restoration of sinus rhythm in .50% of patients. Intravenous
amiodarone administration has a limited and delayed effect but can
slow the heart rate within 12 h; i.v. vernakalant is the most rapidly
cardioverting drug, including patients with mild HF and/or
IHD.99,443 Dofetilide is not used in Europe, and ibutilide is effective
to convert atrial flutter to sinus rhythm.99,444 In patients with AF
and haemodynamic instability, emergency cardioversion (most com-
monly electrical direct current cardioversion) is indicated.99
Alternatively, pharmacological cardioversion using i.v. AADs should
be attempted, if consistent with the patient’s clinical status.
Systemic OAC therapy to prevent thromboembolic events should
be started as soon as possible.99 Post-operative AF is discussed in
Section 8.6.
Management of atrial flutter follows the same principles as AF with
respect to OAC therapy. Rate control is usually an initial approach in
patients with atrial flutter;436 however, drugs that slow atrioventricu-
lar conduction (digoxin, beta-blockers, or non-dihydropyridine
CCBs) are usually less effective than in AF. In patients with a high ven-
tricular rate, electrical cardioversion is frequently needed.445–448
Amiodarone may be an alternative used to control rate, especially
in HF or critically compromised patients.449 Dofetilide and ibutilide
are effective in converting atrial flutter to sinus rhythm, whereas class
IA and IC drugs and amiodarone are less efficient and should not be
used.450–453
6.4.4. Ventricular arrhythmias
Premature ventricular contractions (PVC) and non-sustained VT are
frequent in the general population and patients undergoing NCS.
Specific clinical features have been suggested as predictors of increas-
ing incidence of PVC.454 These arrhythmias have historically been
considered benign; however, recent studies have suggested that
they may be associated with an adverse outcome, even in patients
with apparently normal hearts, especially if frequent (e.g. .10–
20%).455–459 In patients with heart disease, the prognostic impact
of PVC and non-sustained VT depends on type and extent of
heart damage.460–466 In patients undergoing urgent NCS, they
do not require treatment unless frequent and symptomatic.
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If haemodynamically compromising, up-titration of beta-blockers is re-
commended; amiodarone (300 mg i.v. bolus) should be considered if
beta-blockers are not tolerated or contraindicated.467 Further diag-
nostics to rule out significant heart disease is necessary in patients
awaiting elective NCS, especially if frequent, complex (non-sustained
VT), symptomatic, or in those with a positive family history of SCD.
Polymorphic VT and ventricular fibrillation (VF) can be provoked
by ischaemia, electrolyte imbalance, or may be manifestations of pri-
mary electrical disease, such as long-QT or Brugada syndrome.
Monomorphic VT is often associated with the presence of scarred
myocardium. Hence, peri-operative VT or VF in a patient awaiting
surgery should lead to a diagnostic work-up to exclude severe ven-
tricular dysfunction (see Section 4.5.1), and to rule out CAD requiring
prompt revascularization (see Section 6.1) and other potential causes
of arrhythmia (primary electrical disease, dyselectrolytaemia).
Monomorphic VT in patients without overt structural or electrical
heart disease (idiopathic VT, most commonly arising from outflow
tract) is associated with good prognosis and may be left untreated
or, if symptomatic, may be treated with beta-blockers, verapamil,
or sodium channel blockers. Patients with haemodynamically com-
promising VT should undergo electrical cardioversion (after i.v. sed-
ation, if conscious) and VF should be terminated with prompt
defibrillation. Recurrent VT and VF in the setting of acute ischaemia
may be effectively treated with beta-blockers and amiodarone, and
myocardial revascularization in case of obstructive CAD.468
Up-titration of beta-blockers to the maximal tolerated doses can
prevent arrhythmia recurrence.469
Haemodynamically stable, sustained VT should be cardioverted as
a first-line treatment; i.v. procainamide or flecainide may be consid-
ered in patients without HF or myocardial ischaemia. In cases in
which these drugs are unavailable, i.v. amiodarone can be used. In se-
lected cases, when monomorphic VT recurs in patients with scarred
myocardiumwith no reversible causes, despite optimal therapy, inva-
sive electrophysiological study and ablation should be performed
pre-operatively, if NCS can be deferred. After extensive endocardial
VT ablation, treatment with an OAC for a limited period of time
might be reasonable.470,471 A summary of diagnostic and therapeutic
pathways in patients with SVT or VT is shown in Table 12.
Table 12 Peri-operative management of patients with arrhythmias
Type of
arrhythmia
SVT Idiopathic VT in structurally/functionally
normal heart
VT in structural heart
disease
Diagnostics • ECG+ TTEa • ECG+ TTE • ECG + TTE +
biomarkersb
• + Coronary angiography
• + Cardiac CT/MRI
Acute
management
• Vagal manoeuvres
• I.v. adenosine, beta-blocker, CCB
• Electrical cardioversion if unstable
• Vagal manoeuvres
• I.v. beta-blockers/ verapamil
• Electrical cardioversion if unstable
• Treatment of underlying
heart disease
• I.v. beta-blocker
(uptitration), amiodarone
• Electrical cardioversion if
unstable
Prevention of
recurrence
• Per oral beta-blocker, CCB
• Catheter ablation if recurrent despite
OMT (only before high-risk NCS)
• No treatment or
• Per oral beta-blocker, CCB, class I AAD
• Catheter ablation in case of recurrence despite
AADs or drug-intolerance before high-risk NCS
• Per oral beta-blocker,
amiodarone
• Catheter ablation if
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AAD, antiarrhythmic drug; CCB, calcium channel blocker; CT, computer tomography; ECG, electrocardiogram; MRI, magnetic resonance imaging; NCS, non-cardiac surgery; OMT,
optimal medical therapy; SVT, supraventricular tachycardia; TTE, transthoracic echocardiography; VT, ventricular tachycardia.
aBefore high-risk surgery.
bHigh-sensitivity cardiac troponin T/I, and/or BNP/ N-terminal pro-BNP.
Recommendation Table 22 — Recommendations
for management of known or newly diagnosed
arrhythmias
Recommendations Classa Levelb
Supraventricular arrhythmias
In patients with SVT controlled by medication, it is
recommended that AADs are continued during
the peri-operative period.
I C
Ablation should be considered in symptomatic
patients with recurrent or persistent SVT,
despite treatment, prior to high-risk, non-urgent
NCS.437–441
IIa B
AF with haemodynamic instability in patients undergoing
NCS
In AF patients with acute or worsening
haemodynamic instability undergoing NCS,
emergency electrical cardioversion is
recommended.99,472,473
I B
In AF patients with haemodynamic instability,
amiodarone may be considered for acute control
of heart rate.99
IIb B
Continued
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6.4.5. Bradyarrhythmias
Temporary cardiac pacing during the peri-operative period should
be limited to patients undergoing urgent NCS, if bradycardia is
haemodynamically compromising despite i.v. chronotropic drugs,
or provokes episodes of ventricular tachyarrhythmia.481 In patients
undergoing elective NCS, surgery should be deferred if possible,
and permanent pacemaker should be implanted, if indications for pa-
cing are fulfilled.481 Prophylactic pacing in the settings of asymptom-
atic bifascicular block, with or without first-degree atrioventricular
block, is generally not indicated, and chronotropic drugs (atropine,
isoprenaline, adrenaline, or, alternatively, aminophylline, dopamine,
or glucagon in beta-blocker or CCB overdosing) are usually effective.
Patients with bifascicular bundle branch block or prolonged
His-ventricular interval are at an increased risk of developing com-
plete heart block.482,483 Equipment needed to perform emergent
transcutaneous pacing and personnel able to perform such a proced-
ure should be immediately available during NCS in patients with bi-
fascicular block; alternatively, a permanent pacemaker may be
implanted.481
6.4.6. Management of patients with cardiac
implantable electronic devices
Patients with CIEDs can undergo NCS, pending adequate peri-
operative device management. A pre-operative check should have
been performed at least once within the 12 months preceding sur-
gery for pacemaker patients and within 6 months for patients with
ICD, in the absence of any malfunction (remote monitoring can
also be used for check-ups).484,485 In pacing-dependent patients, pa-
tients with biventricular pacing for CRT, and ICD-recipients under-
going elective NCS associated with risk of electromagnetic
interference (EMI) (e.g. involving the use of unipolar electrocoagula-
tion, especially above the umbilicus), CIED check and reprogramming
should be performed immediately before surgery. In pacemaker-
dependent patients, devices should be reprogrammed to non-
sensing or asynchronous pacing mode to protect against inhibition
of the pacemaker. This can be performed in the majority of pace-
maker models by placing a magnet over the pacemaker can.486,487
However, magnet mode in modern pacemakers, except Medtronic
and Sorin/Livanova/Microport, is programmable and may not be
asynchronous pacing; thus, magnet application is not a universal rem-
edy against EMI-induced malfunction. Furthermore, asynchronous
pacing may lead to pacing on the T wave, which can provoke VT/
VF. However, the risk of clinically significant EMI is low487–489 and
a practical solution would be to monitor the patient via plethysmo-
graphy or an arterial line, and limit the use of electrocautery if pauses
occur during ECG monitoring.
Patients with leadless pacemakers may safely undergo surgery,
with precautions similar to patients with conventional pacemakers,
avoiding EMI and after reprogramming the pacemaker into non-
sensing mode in pacing-dependent patients (due to its intracardiac
location and lack of a Hall-effect sensor/reed switch, this device can-
not be temporarily reprogrammed to an asynchronous mode with a
magnet applied over the body of the pacemaker).490,491
In patients with ICDs undergoing NCSwith anticipated risk of EMI,
arrhythmia detection or antiarrhythmic therapies through the device
should be switched off before NCS,492 or a magnet should be put
over the device.488,489,492 All modern ICDs will respond to magnet
application by inhibiting antitachycardia therapy, while the brady pa-
cing is left intact. Deactivation by programming mandates telemetry
and cardioversion equipment until reactivation, which may be im-
practical. Furthermore, there is a risk that the patient is discharged
without the device being reactivated. These factors would favour
the use of a magnet instead of deactivation. In some patients where
the device is inaccessible for magnet application, a magnet cannot be
used and reprogramming is mandatory. From this point onwards,
throughout the whole procedure until reactivation of the ICD, the
patient should have continuous ECG monitoring, and personnel
skilled in early detection of arrhythmias, defibrillation, and cardiopul-
monary resuscitation manoeuvres should be present. As soon as
possible after NCS, it is recommended that the ICD is checked
and therapies switched on.485
Patients with subcutaneous ICD can undergo surgery after switch-
ing off the antiarrhythmic therapy or magnet application; however, if
thoracic surgery is planned, especially with a median sternotomy, the
surgeon should be aware of the presence of the ICD and the
course of the subcutaneous electrode. This can prevent mechanical
damage of the lead, the direct use of electrocautery on the electrode,
or the placement of sternal wires in close proximity to the sensing
electrodes.493
In pacing-dependent patients, patients with CRT, and ICD pa-
tients, EMI with the device should be avoided (e.g. with electro-
cautery). Use of bipolar electrocautery, short bursts of impulses
limited to several seconds (,5 s), with the lowest effective energy,
and operating with a pen or stylus away from the device (.15 cm)
can minimize the risk of interference with the device. In the case
of unipolar electrocoagulation, the electrosurgical unit should be
connected in a way that keeps the current circuit away from the
CIED can and electrodes. However, the manufacturer’s recommen-
dations should be considered (usually recommending placement of
the indifferent electrode on the opposite site of the body to the
one operated on, but possibly close to the surgical site, on a well-
vascularized, muscular area). Consequently, the indifferent return
pad should be placed as far away from the CIED as possible, keeping
the surgical site between the CIED and the return electrode
(Figure 15).494–497
In patients with implantable loop recorders (especially those not
undergoing remote monitoring and regular downloads of the
CIED memory), the device memory download is to be considered
Ventricular arrhythmias
In patients with symptomatic, monomorphic,
sustained VT associated with myocardial scar,
recurring despite optimal medical therapy,
ablation of arrhythmia is recommended before
elective NCS.474–480
I B
It is not recommended to initiate treatment of
asymptomatic PVC during NCS.
III C
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AAD, antiarrhythmic drug; AF, atrial fibrillation; NCS, non-cardiac surgery; PVC,
premature ventricular contractions; SVT, supraventricular tachycardia; VT, ventricular
tachycardia.
aClass of recommendation.
bLevel of evidence.
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before procedures associated with possible EMI, or involving the ana-
tomical location close to the device, to avoid misrecognizing and re-
cording noise as arrhythmia or erasing the memory.498,499
6.5. Adult congenital heart disease
Adults with congenital heart disease (ACHD) account for .60% of
the population with congenital heart disease (CHD).500,501
Accordingly, ACHD represent an increasing proportion of NCS ad-
missions502 and might be at high risk of CV events.
Pre-operative risk assessment in ACHD needs to focus on the
underlying disease, type of surgery, residua, and sequelae.503
Coexistence of HF, pulmonary hypertension, arrhythmia, hypox-
aemia, damage to other organs, and endocarditis may considerably
influence the baseline risk of these patients from no additional risk
to very high risk of worse prognosis.503,504 Thus, original medical
and surgical reports should be obtained along with current data,
which should include symptoms, exercise capacity, oxygen satur-
ation, laboratory values (BNP, haemoglobin, creatinine, etc.), and
medication.
Recommendation Table 23— Recommendations for
management of bradyarrhythmia and patients carry-
ing cardiac implantable devices
Recommendations Classa Levelb
If indications for pacing exist according to the
2021 ESC Guidelines on cardiac pacing and
cardiac resynchronization therapy,481 NCS
surgery should be deferred and implantation of a
permanent pacemaker should be considered.
IIa C
It is recommended that patients with temporarily
deactivated ICDs have continuous ECG
monitoring, and during the peri-operative period
are accompanied by personnel skilled in early
detection and treatment of arrhythmias. In
high-risk patients (e.g. pacemaker-dependant or
ICD patients), or if access to the torso will be
difficult during the procedure, it is recommended
to place transcutaneous pacing/defibrillation pads
prior to NCS.
I C
It is recommended that all patients with CIEDs
that are reprogrammed before surgery have a
re-check and necessary reprogramming as soon as
possible after the procedure.
I C
Continued
In high-risk CIED patients (e.g. with ICD or being
pacing-dependant) undergoing NCS carrying a
high probability of electromagnetic interference
(e.g. involving unipolar electrosurgery above the
umbilical area), CIED check-up and necessary
reprogramming immediately before the
procedure should be considered.
IIa C
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CIED, cardiac implantable electronic device; ECG, electrocardiogram; ICD, implantable
cardioverter–defibrillator; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
A B C
Electric knife
Return
electrode
CIED
Figure 15Optimal location of return electrode during unipolar electrosurgery in patients with cardiac implantable electronic devices, depending on the
surgery site. CIED, cardiac implantable electronic device. Use of bipolar electrocautery, short (,5 s) bursts of impulses, with the lowest effective energy,
operating with pen or stylus away (.15 cm) from the device can minimize the risk of interference with the device. (A) Surgery site on ipsilateral site above
CIED. (B) Surgery on ipsilateral site below CIED. (C ) Surgery on contralateral site.494
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In a recent report, absolute mortality in ACHD patients undergo-
ing NCS exceeded 4%.502 Mortality and peri-operative morbidity
were greater in ACHD compared with a matched comparison co-
hort, and patients with severe ACHD had the highest mortality
rate. It is well known that patients with pulmonary hypertension
and with Eisenmenger syndrome have a higher risk of complica-
tions.505 A large registry confirmed these findings: patients with se-
vere CHD had an increased risk of 30 day mortality, overall
mortality, and reintubation, while patients with intermediate CHD
had a moderate increase in overall mortality and risk of reintuba-
tion.506 Based on this study and recent guidelines,503 the classification
in Table 13 is proposed for risk stratification.
A consultation by an ACHD specialist is necessary, especially in pa-
tients with intermediate or severe ACHD scheduled for
intermediate- or high-risk NCS. It is recommended that elective sur-
gery in intermediate- and severe-risk ACHD patients should take
place in centres experienced in the management of ACHD patients.
It is generally recommended to perform the least invasive proce-
dures and anaesthesia with as low an impact on haemodynamics as
possible.
Optimal peri-operative care in ACHD undergoing NCS starts
with a proper pre-operative evaluation. Adults with congenital heart
disease can present with multiorgan involvement (kidneys, liver, lung,
and endocrine system), which should be considered during the diag-
nostic work-up.503 In many cases, patients with ACHD have a lifelong
indication for OAC therapy or antithrombotic treatment, mainly due
to arrhythmias or increased thromboembolic risk associated with
specific ACHD. Oral anticoagulant therapy in the peri-operative
phase should be re-evaluated on a case-by-case basis. The
CHA2DS2-VASc score has not been validated in ACHD patients
and should not be used in this group.
Continuous haemodynamic monitoring can be necessary in pa-
tients with ACHD and should include invasive BP monitoring, espe-
cially in cases with ACHD of moderate or severe complexity. It is
worth mentioning that, according to the type of ACHD or surgery
(e.g. coarctation of the aorta or following a Blalock-Taussig shunt),
the location of the arterial line for continuous BP and gas exchange
monitoring requires careful attention. In patients with persistent
right-to-left shunts, air filters must be used for venous access.
Ventilator management and extubation can be complicated by the
presence of restrictive lung disease.507 Antibiotic prophylaxis for
endocarditis should be given according to the 2015 ESC Guidelines
for the management of infective endocarditis.432 Furthermore, post-
operative care in an ICU with experience in handling ACHD patients
is often necessary.
A prolonged monitoring period in this setting should be consid-
ered, with a special focus on arrhythmias and an optimal volume
management, as it has been shown that up to 50% of adverse events
were attributable to lapses in the post-operative monitoring and
care.508 Two groups at special risk are patients with chronic cyanosis
and those after the Fontan procedure. Chronic cyanosis is associated
with multiorgan involvement. Furthermore, bleeding risk is higher
due to multiple collaterals, platelet dysfunction, and alterations in
the coagulation cascade.509 In patients with Eisenmenger syndrome,
conditions that increase pulmonary vascular resistance such as hypo-
thermia, metabolic acidosis, hypercapnia, and hypovolaemia must be
avoided.509 This is also true for patients after the Fontan procedure,
where venous return relies on low pulmonary pressures. If
intra-abdominal pressure rises too high in these patients, venous re-
turn is drastically reduced, with a subsequent drop in cardiac output.
These haemodynamic aspects should be carefully considered in cases
of laparoscopic or open NCS.
6.6. Pericardial diseases
Active pericardial disease is infrequent at the time of NCS, but po-
tentially life-threatening. The clarification of underlying aetiology is
of utmost importance for peri-operative management (viral or bac-
terial infection, malignant, systemic autoimmune, metabolic, or auto-
reactive disease). The treatment of these conditions should follow
the recommendations provided in the 2015 ESC Guidelines for
the diagnosis and management of pericardial diseases.510
Acute pericarditis is a clear indication to postpone an elective sur-
gical procedure. However, in cases of undeferrable NCS, attention is
required regarding drug-to-drug interactions. The frequently used
colchicine is predominantly metabolized through the liver, while re-
nal excretion accounts for only 10–20%. Colchicine may increase
Recommendation Table 24— Recommendations for
management of patients with adult congenital heart
disease undergoing non-cardiac surgery
Recommendations Classa Levelb
In patients with ACHD, a consultation with an
ACHD specialist is recommended before
intermediate- or high-risk surgery.
I C
In patients with ACHD, it is recommended that
intermediate- and high-risk elective surgery is
performed in a centre with experience in the care
of ACHD patients.
I C
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ACHD, adults with congenital heart disease.
aClass of recommendation.
bLevel of evidence.
Table 13 Risk stratification for non-cardiac surgery
in adults with congenital heart disease
Minor risk Patients with small, uncorrected defects, and no
need for medication or any other treatment
Patients with successfully corrected CHDwith no
symptoms, no relevant residua, and no need for
medication
Intermediate
risk
Patients with corrected or uncorrected
conditions with residual haemodynamic
abnormality, with or without medication
Severe risk Patients with uncorrected cyanotic heart disease,
pulmonary hypertension, other complex CHD,
ventricular dysfunction requiring medication, and
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CHD, congenital heart disease.
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sensitivity to central nervous system depressants and exert a respira-
tory depressant effect.511 Adverse events of peri-operative signifi-
cance include diarrhoea, worsening renal failure, and, very rarely,
bone marrow suppression, hepatotoxicity, paralysis, convulsions,
and cardiopulmonary collapse. Immunosuppressive drugs such as
steroids and interleukin-1 receptor antagonist agents suppress the
immune system, and may increase the risk of infection and delay
wound healing in the peri-operative phase.511
Imminent cardiac tamponade is an absolute contraindication for all
surgical procedures, especially when a general anaesthesia is re-
quired.510,512 Before NCS, pericardial effusion should first be percu-
taneously drained, under local anaesthesia. In cases of small or
moderate chronic pericardial effusion and constrictive pericarditis,
attention should be paid to take measurements to increase cardiac
pre-load. The pre-load should be optimized peri-operatively with
i.v. fluids prior to general anaesthetic induction to facilitate ventricu-
lar filling. Manipulation and medication diminishing venous return to
the heart should be avoided or minimized. Positive pressure ventila-
tion might cause a dramatic decline in pre-load and should be
avoided. If spontaneous breathing is not possible, ventilation with
minimal inspiratory pressures (low tidal volumes, high respiratory
rate) should be considered. Anaesthetics that minimize changes in
heart rate, systemic vascular resistance, venous return, and myocar-
dial contractility should be selected.189 Ketamine, a sympathetic
stimulant that preserves spontaneous ventilation, is the drug of first
choice. Combinations of opiates, benzodiazepines, and nitric oxide,
with or without low doses of volatile anaesthetics, are acceptable
for maintenance of anaesthesia. Muscle relaxants with minimal circu-
latory effects should be preferred, although the modest increase in
heart rate observed with administration of pancuronium is also
acceptable.
6.7. Pulmonary disease and pulmonary
arterial hypertension
The coexistence of pulmonary disease in cardiac patients undergoing
NCS may increase the operative risk. Pre-existing pulmonary disease
has a significant impact on peri-operative risk, but the most common
effect is an increase in the risk of post-operative pulmonary compli-
cations. These complications particularly occur after abdominal or
thoracic surgery, and the risk seems to be increased in smokers.
Certain respiratory conditions are associated with CV pathology
and may require special cardiac risk assessment and management,
in addition to dealing with the pulmonary disease per se. Three
such conditions are chronic obstructive pulmonary disease
(COPD), obesity hypoventilation syndrome, and pulmonary arterial
hypertension (PAH).
6.7.1. Pulmonary disease
Chronic obstructive pulmonary disease is as a major cause of mor-
bidity and mortality.513 Although patients with COPD have an in-
creased risk of CVD, there is no evidence that COPD is related to
a higher risk of peri-operative cardiac complications. However,
post-operative pulmonary complications result in significant mor-
tality and morbidity. Pre-operative evaluation, using specific post-
operative pulmonary complication tools, can be used to stratify
at-risk patients and enable optimal pre-operative and peri-
operative management.514 In patients with COPD undergoing
NCS, the pre-operative treatment goals are to optimize pulmon-
ary function and minimize post-operative respiratory complica-
tions; this includes using the pre-operative period for education,
including possible cessation of smoking (2 months before surgery),
instruction concerning chest physiotherapy and lung expansion
manoeuvres, muscular endurance training, and re-nutrition if re-
quired. Beta-adrenergic agonists and anticholinergic agents should
be continued until the day of surgery in all symptomatic COPD pa-
tients with bronchial hyper-reactivity. In some cases, short-term
systemic/inhaled steroids may be considered. Where there is ac-
tive pulmonary infection, appropriate antibiotics should be admi-
nistered for at least 10 days and, if possible, elective NCS should
be deferred.515
Obesity hypoventilation syndrome is defined as the triad of obes-
ity, daytime hypoventilation, and sleep-disordered breathing.
Although distinct from simple obesity and sleep apnoea, it is esti-
mated that 90% patients with obesity hypoventilation syndrome
also have obstructive sleep apnoea (OSA). The prevalence of obesity
hypoventilation syndrome is 0.15–3% of adults and 7–22% in patients
undergoing bariatric surgery.516 Obesity hypoventilation syndrome is
associated with even higher morbidity, including HF (and
obesity-related cardiomyopathy), angina pectoris, pulmonary hyper-
tension (30–88%) and cor pulmonale, and increased peri-operative
mortality.516 Patients at high risk of obesity hypoventilation syn-
drome who are undergoing NCS should be referred for additional
specialist investigation of sleep-disordered breathing and pulmonary
hypertension, with pre-operative initiation of appropriate
positive airway pressure therapy, and planning of peri-operative
techniques (anaesthetic and surgical) and post-operative positive air-
way pressure management within an appropriate monitored
environment.516,517
6.7.2. Pulmonary arterial hypertension
Pulmonary arterial hypertension is associated with increased
morbidity and mortality in patients undergoing NCS.518
Recommendation Table 25— Recommendations for
pericardial diseases
Recommendations Classa Levelb
In patients with acute pericarditis, deferring
elective NCS until complete resolution of the
underlying process should be considered.
IIa C
Avoiding elective NCS procedures under general
anaesthesia until colchicine or the
immunosuppressive treatment course for
pericardial disease is completed may be
considered.
IIb C
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NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
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A meticulous pre-operative diagnostic work-up in this subset of
patients should include assessment of functional status and se-
verity of disease, in addition to comorbidities and the type of
NCS. Echocardiography and right heart catheterization (if clinic-
ally indicated) are key components in the pre-operative work-up.
The morbidity and mortality associated with PAH derive from
the haemodynamic response of the right ventricle to acute in-
creases in afterload.519
In patients with severe PAH, peri-operative mortality ranging
between 3–18% has been reported, depending on the
severity of the underlying disease, and the nature and urgency of
the surgical procedure. Emergency procedures are also associated
with a high risk of complications.520,521 Patient-related and
surgery-related factors should be considered when assessing peri-
operative risk in patients with PAH (Table 14).522 Owing to the
potential for anaesthesia and surgery to be complicated by acute
right HF and pulmonary hypertensive crisis, elective NCS in pa-
tients with PAH should be adequately discussed in a multidisciplin-
ary team. Ideally, patients with PAH undergoing NCS should have
optimal medical treatment before surgery and be managed in a
centre experienced in PAH. Patients scheduled for NCS should
be discussed by a pneumologist, cardiologist, surgeon, and an
anaesthesiologist.523 The management of patients with PAH in
the peri-operative setting should follow the recommendations
provided in the 2022 ESC/ERS Guidelines for the diagnosis and
treatment of pulmonary hypertension.524
Several novel therapies aimed at reducing pulmonary pressures
are used pre-operatively in patients undergoing NCS. Of these
therapies, endothelin receptor antagonists, phosphodiesterase
inhibitors, and prostacyclin analogues are the most used.525
This medication should be continued during the peri-operative
phase because therapy disruption may lead to a critical rebound
of the PAH. Inhaled nitric oxide allows selective pulmonary vaso-
dilatation with rapidity of action and it can be given to patients
who develop worsening pulmonary hypertension post-
operatively to maintain right ventricular (RV) function and
haemodynamic stability.526
6.8. Arterial hypertension
The prevalence of arterial hypertension in adults in Europe is
30–45%.527 Of these patients, ,40% have well-controlled BP
(,140/90 mmHg). A large observational study has shown that pa-
tients with untreated hypertension 1 month before surgery had a
69% increased risk of 90 day post-operative mortality.183 Further,
overall CV risk assessment, including the search for hypertension-
mediated organ damage, is of paramount importance in hyperten-
sive patients, and mandatory when there is newly detected BP
elevation.528
Postponing surgery is usually not advised in patients with grade
1 or 2 hypertension. In contrast, in subjects with a systolic BP
≥180 mmHg and/or diastolic BP ≥110 mmHg, deferring the
intervention until BP is under control is advisable, except for
emergency surgery.236,527,529,530 It also seems important to avoid
large peri-operative BP fluctuations. In a recent randomized trial
among patients undergoing abdominal surgery, an individualized
intra-operative treatment strategy with systolic BP values kept
within a 10% difference from the pre-operative office measure-
ment resulted in a reduced risk of post-operative organ dysfunc-
tion.528 In a meta-analysis including 130 862 patients undergoing
surgery, intra-operative hypotension was associated with
Table 14 Patient-related and surgery-related fac-
tors to be considered when assessing peri-operative
risk in patients with pulmonary arterial hypertension
Patient-related
peri-operative risk factors
in patients with PAH
Surgery-related
peri-operative risk factors in
patients with PAH
• Functional class .II
• Reduced six-minute walk
distance
• Coronary heart disease
• Previous pulmonary embolism
• Chronic renal insufficiency
• Severe right ventricular
dysfunction
• Emergency surgery
• Duration of anaesthesia .3 h
• Intra-operative requirement for
vasopressors
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PAH, pulmonary arterial hypertension.
Adapted from Olsson et al.522
Recommendation Table 26— Recommendations for
patients with pulmonary arterial hypertension under-
going non-cardiac surgery
Recommendations Classa Levelb
It is recommended to continue chronic therapy
for PAH in the peri-operative phase of NCS.
I C
It is recommended that haemodynamic
monitoring of patients with severe PAH continues
for at least 24 h in the post-operative period.
I C
In the case of progression of right HF in the
post-operative period in patients with PAH, it is
recommended that the diuretic dose be
optimized and, if necessary, i.v. prostacyclin
analogues be initiated under the guidance of a
physician experienced in the management of PAH.
I C
Inodilator drugs (dobutamine, milrinone,
levosimendan), which increase cardiac output and
lower pulmonary vascular resistance, should be
considered peri-operatively according to the
haemodynamic status of the patient.
IIa C
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HF, heart failure; i.v., intravenous; NCS, non-cardiac surgery; PAH, pulmonary arterial
hypertension.
aClass of recommendation.
bLevel of evidence.
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increased risk of morbidity (OR, 2.08; 95% CI, 1.56–2.77), mortal-
ity (OR, 1.94; 95% CI, 1.32–2.84), cardiac complications (OR,
2.44; 95% CI, 1.52–3.93), and AKI (OR, 2.68; 95% CI, 1.31–
5.55).531 In patients with hypertension, hypoperfusion may occur
at higher BP levels and peri-operative BP control should be tai-
lored to pre-operative levels.528
In patients referred for elective NCS, control of BP should be
prioritized, especially in patients with systolic BP .160 mmHg.
The management of patients with hypertension in the pre-operative
setting should follow the recommendation provided in the 2018
ESC/European Society of Hypertension (ESH) Guidelines for the
management of arterial hypertension.529 These guidelines advocate
an approach using RAAS inhibitors (in patients aged ,70 years) or
CCBs (in patients aged .70 years) as single therapy in moderate
hypertension and both in combination where dual therapy is
needed, adding a diuretic and an aldosterone antagonist if addition-
al medication is needed for adequate control. Beta-blockers are re-
stricted to patients where it is specifically indicated.529 In patients
with hypertension and a clear indication for beta-blocker, third-
generation beta-blockers—such as carvedilol, celiprolol, labetolol,
and nebivolol—have superior antihypertensive effects compared
with other beta-blockers and fewer adverse effects, but there
are no RCTs reporting outcomes in hypertensive patients.529 In
a large observational study, a beta-blocker prescription prior to
NCS was associated with lower 30 day mortality in patients with
three or four cardiac risk factors.188 However, for patients with
no cardiac risk factors, the risk of death was significantly increased
with beta-blockers.188,532
Most patients with stage 3 hypertension on the day of surgery
will be classified as hypertensive urgencies. In these cases, the
2018 ESC/ESH Guidelines for the management of arterial hyper-
tension recommend ACEIs, CCBs, or diuretics. Neither ACEIs
nor diuretics are recommended on the day of surgery. The use
of CCBs is supported by a meta-analysis of 11 studies of CCBs dur-
ing NCS.220 Further, a study of 989 well-controlled patients with
hypertension without hypertension-related organ damage, testing
the use of fast-acting nasal nifedipine when stage 3 hypertension
(systolic BP.180 and/or diastolic BP.110 mmHg) was diagnosed
the day of NCS, found no difference in outcome between admin-
istration of nifedipine and surgery on the same day compared with
deferral for hypertension control before resuming surgery.533
Immediate nifedipine treatment was associated with shorter hos-
pital stays. As this was the first study testing the need for deferral
of stage 3 hypertension, it challenged the need for this practice. For
patients with hypertensive emergencies (systolic BP .180 and/or
diastolic BP .110 mmHg and organ damage), the 2018 ESC/ESH
Guidelines for the management of arterial hypertension recom-
mend labetolol, nitroglycerin, nitroprusside, etc., according to
the affected organ.529
The timing of administration of the antihypertensive drugs, and
their continuation or discontinuation in the peri-operative period
is discussed in Section 5.2.
6.9. Peripheral artery disease
Patients with peripheral artery disease (PAD) usually have advanced
atherosclerotic disease affecting multiple vascular beds in varying de-
grees and have a worse prognosis compared with patients without
PAD.534–538 Patients with PAD generally differ in their risk profiles, ac-
cording to whether they undergo vascular or non-vascular NCS.
6.9.1. Peripheral artery disease and non-vascular
non-cardiac surgery
Decisions on pre-operative treatment of pre-existing PAD and AAA
in patients scheduled for non-vascular NCS should be made on an
individual basis, taking into account symptoms and risks of surgery.
Non-cardiac surgery should be prioritized in patients needing revas-
cularization for PAD, but careful peri-operative monitoring of deteri-
oration in lower extremity perfusion is warranted, particularly in
those patients with chronic limb-threatening ischaemia (e.g. periph-
eral BP of ≤50–70 mmHg in the foot joint and ≤30–50 mmHg in
the toes).539 For patients with AAA, pain control is essential to
ensure stable BP, minimizing rupture risk. Patients with large AAA
(i.e. .5 cm in diameter for women and .5.5 cm for men) should
be evaluated for aortic aneurysm repair (preferably EVAR)540–542
before non-vascular NCS is planned, particularly in the case of
malignant tumours, depending on the stage of malignant disease.
6.9.2. Peripheral artery disease and vascular
non-cardiac surgery
The 2017 ESC Guidelines on the diagnosis and treatment of periph-
eral arterial diseases535 and the European Society for Vascular
Surgery (ESVS) 2019 Clinical Practice Guidelines on the management
of abdominal aorto-iliac artery aneurysms35 provide detailed evidence
and recommendations on the screening of patients before vascular
Recommendation Table 27— Recommendations for
pre-operative management of hypertension
Recommendations Classa Levelb
In patients with chronic hypertension undergoing
elective NCS, it is recommended to avoid large
peri-operative fluctuations in blood pressure,
particularly hypotension, during the
peri-operative period.528,531
I A
It is recommended to perform pre-operative
screening for hypertension-mediated organ
damage and CV risk factors in newly diagnosed
hypertensive patients who are scheduled for
elective high-risk NCS.
I C
It is not recommended to defer NCS in patients
with stage 1 or 2 hypertension.
III C
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CV, cardiovascular; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
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NCS and their treatment modality selection. Notably, there is rando-
mized evidence against prophylactic coronary revascularization be-
fore major vascular surgery in CCS patients due to lack of benefit
in improvement of peri-operative and long-term outcomes (2.7 years
mean follow-up).399 Assessment of functional capacity might offer
guidance to select candidates for cardiac assessment prior to major
NCS, although severe walking impairment may challenge this test.
The previously established risk predictive model to detect mortality
in patients undergoing elective AAA repair may be helpful.543
Low-dose rivaroxaban plus aspirin initiatedwithin 10 days after a low-
er limb revascularization procedure reduces post-operative throm-
botic events (acute limb ischaemia, amputation, MI, ischaemic
stroke, and CV death) in patients undergoing lower limb revascular-
ization, whether it is carried out using an endovascular or open sur-
gical approach.544 Handling of other co-drugs should follow the
recommendations detailed in Section 5.2.
6.10. Cerebrovascular disease
Patients undergoing NCS should be questioned about previous neuro-
logical symptoms, and those with symptoms suggestive of transient is-
chaemic attack (TIA) or stroke in the preceding 6 months should
undergo pre-operative neurological consultation and neurovascular and
brain imaging, if appropriate. In the absence of dedicated studies addres-
sing this issue, thecriteria for carotid revascularization in symptomatic and
asymptomatic patients is described in detail in the 2017 ESC Guidelines
on the diagnosis and treatment of peripheral arterial diseases, in collabor-
ation with the ESVS; these guidelines should also guide the management
of patients with carotid disease who are undergoing NCS.535
In patients with symptomatic carotid disease, the benefit of carotid
revascularization is particularly high in patients with recent (,3
months) TIA or stroke, and ≥70% carotid artery stenosis. Thus, ca-
rotid revascularization should be performed first and elective NCS
should be postponed.545
The question as to whether patients with severe asymptomatic ca-
rotid occlusive disease who are undergoing elective major NCS re-
quire pre-operative carotid revascularization remains a matter of
debate. Importantly, the purpose of carotid revascularization in this
setting is more the long-term prevention of stroke than peri-
operative stroke risk reduction; therefore, if carotid revascularization
is indicated, this may be performed before or after the planned NCS.
Independent of the revascularization strategy, patients with carotid
artery stenosis benefit from aggressive CV risk-factor modification
to prevent peri-operative myocardial ischaemia.
6.11. Renal disease
Renal disease is associated with several cardiac comorbidities, including
hypertension, HF, CAD, and arrhythmias.546 Consistently, renal disease
portends a significant increase in the post-operative risk of CV events,
includingMI, stroke, and progression of HF in patients undergoingNCS.
For this reason, most risk indices for the quantification of pre-operative
risk in patients undergoing NCS include renal function.
Chronic kidney disease (CKD) is defined as impaired kidney func-
tion or raised proteinuria, confirmed on two or more occasions at
least 3 months apart. The kidney function can be assessed through
the estimated glomerular filtration rate (eGFR) calculated using the
Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) for-
mula, including sex, age, ethnic origin, and serum creatinine concen-
tration. A cut-off glomerular filtration rate (GFR) value,60 mL/min/
1.73 m2 significantly correlates with MACEs. Identification of cardiac
patients at risk of worsening of renal function in the peri-operative
phase of NCS is of paramount importance, in order to initiate sup-
portive measures such as maintenance of adequate intravascular vol-
ume for renal perfusion and use of vasopressors.547
Patients with cardiac comorbidities are prone to develop AKI after
major NCS, due to worsening of haemodynamic status associated
with fluids or blood loss, and withdrawal or continuation of
cardio-active therapies. The peri-operative management of patients
undergoing NCS and treated with cardio-active drugs has been dis-
cussed in Section 5.2. Acute kidney injury reduces long-term survival
in patients with normal baseline renal function.548 Of interest,
30–40% of all cases of AKI occur after surgery and the incidence
of post-operative AKI ranges 18–47%. Risk factors for the develop-
ment of post-operative AKI following NCS include cardiac
RecommendationTable 28—Recommendations for
management of patients with peripheral artery dis-
ease and/or abdominal aortic aneurysm undergoing
non-cardiac surgery
Recommendations Classa Levelb
In patients with poor functional capacity or
significant risk factors or symptoms (such as
moderate-to-severe angina pectoris,
decompensated HF, valvular disease, and
significant arrhythmia), referral for cardiac
work-up and optimization is recommended prior
to elective surgery for PAD or AAA.
I C
Routine referral for cardiac work-up, coronary
angiography, or CPET prior to elective surgery for
PAD or AAA is not recommended.
III C
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AAA, abdominal aortic aneurysm; CPET, cardiopulmonary exercise testing; HF, heart
failure; PAD, peripheral artery disease.
aClass of recommendation.
bLevel of evidence.
Recommendation Table 29— Recommendations for
management of patientswith suspected or established
carotid artery disease undergoing non-cardiac surgery
Recommendations Classa Levelb
Pre-operative carotid artery and cerebral imaging
is recommended in patients with a history of TIA
or stroke in the previous 6 months and who have
not undergone ipsilateral revascularization.
I C
For patients with carotid artery disease
undergoing NCS, the same indications for carotid
revascularization should be considered as for
other patients with carotid stenosis.
IIa C
Pre-operative carotid artery imaging is not
recommended routinely in patients undergoingNCS.
III C
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NCS, non-cardiac surgery; TIA, transient ischaemic attack.
aClass of recommendation.
bLevel of evidence.
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(decompensated or chronic HF, hypertension, cardio-active drugs)
and non-cardiac triggers (age, sex, emergent, and/or intraperito-
neal surgery, mild pre-operative renal insufficiency, pre-operative
creatinine elevation, CKD, and DM).549,550 The combination of a
low cardiac output/high venous pressure and/or the administration
of iodinated contrast media during diagnostic and operative proce-
dures represent the most frequent causes of AKI in hospitalized car-
diac patients, regardless of pre-existing impaired renal function.
Contrast-induced AKI is defined as a rise in serum creatinine of
44 mmol/L (0.5 mg/dL) or a 25% relative rise from baseline at 48 h
(or 5–10% at 12 h) following contrast administration. It occurs in
up to 15% of patients with CKD who are undergoing radiographic
procedures.551 Although most cases of contrast-induced AKI are
self-limiting, with renal function returning to normal within 7 days
of the procedure, these patients occasionally (0.5–12% of cases) de-
velop overt renal failure associated with increased morbidity and
mortality. To reduce the risk of contrast-induced AKI in subjects re-
quiring contrast-enhanced radiography, the Kidney Disease:
Improving Global Outcomes (KDIGO) Clinical Practice Guidelines
recommend: pre-operative hydration with i.v. isotonic fluids; the
use of the minimum volume of contrast media; and the use of low-
osmolar or iso-osmolar contrast media, regardless of pre-existing re-
nal disease.547 In the post-operative phase, kidney function should be
monitored by applying established AKI scoring systems to raise
awareness and enable early intervention.552
6.12. Obesity
The prevalence of people being overweight and having obesity is
reaching epidemic proportions in Western countries557 and is the
second leading cause of preventable death following tobacco
use.558 Obesity is defined as a body mass index (BMI) of ≥30 kg/m2,
morbid obesity as a BMI ≥35 kg/m2, and super-morbid obesity as a
BMI ≥50 kg/m2. Obese individuals have a higher prevalence of CV
risk factors and a higher risk of death,559 and are a population who
are at increased risk of adverse events in the case of surgical proce-
dures. There are specific recommendations for the pre-operative
risk assessment of obese patients undergoing NCS, regardless of the
presence of pre-existing cardiac conditions.560 However, while obes-
ity accelerates the propensity for CVD, it seems that many types of
CVD may have a better prognosis in the overweight population com-
pared with their leaner counterparts, a phenomenon that is known as
the ‘obesity paradox’.561,562 Similarly, in cases ofNCS,mildly obese pa-
tients present lower mortality risk compared with underweight and
normal weight patients, both post-operatively and at long-term
follow-up.563 This finding may be related to the lower prevalence of
PMI in mildly obese patients undergoing NCS.564
It has been suggested that cardiorespiratory fitness (CRF), rather
than BMI, should be used to assess CV risk in obese patients. While
the classification based on BMI is simple, highly reproducible, and
widely adopted in clinical practice, it does not reflect fat distribution
and body composition. Cardiorespiratory fitness refers to the ability
of the circulatory and respiratory systems to supply oxygen to skel-
etal muscles during sustained physical activity, which is of paramount
importance, especially in patients with cardiac diseases. The primary
measure of CRF is VO2 max.
565 A cohort study of nearly 10 000 pa-
tients with CAD followed for almost 15 years showed that those
with relatively good CRF had favourable prognosis regardless of
body composition;566 however, a lower CRF was found to be a
major predictor of mortality, regardless of BMI.561,567 Whether
specific optimization and/or treatment strategies might have a
positive impact on the outcome of obese patients with pre-
existing or newly diagnosed cardiac comorbidities and scheduled
for NCS is a matter of ongoing controversy. Studies assessing
the effect of weight loss interventions (low-energy diets with or
without an exercise component) on clinical outcomes in patients
undergoing NCS found inconsistent results in terms of peri-
operative morbidity or mortality.568,569
Recommendation Table 30— Recommendations for
management of patientswith renal disease undergoing
non-cardiac surgery
Recommendations Classa Levelb
In patients with renal disease requiring
peri-operative contrast-enhanced radiography,
balanced hydration with i.v. isotonic fluids, the use
of a minimal volume of contrast media, and the
use of low-osmolar or iso-osmolar contrast media
should be considered.547,553–555
IIa B
In patients with known risk factors (age .65
years, BMI .30 kg/m2, diabetes, hypertension,
hyperlipidaemia, CV disease, or smoking)
undergoing intermediate- or high-risk NCS, it is
recommended to screen for pre-operative renal
disease by measuring serum creatinine and GFR.
I C
If a cystatin C measurement assay is available,
cystatin C measurement should be considered in
patients with impaired eGFR (,45–59 mL/min/
1.73 m2) to confirm kidney disease.556
IIa C
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BMI, body mass index; CV, cardiovascular; eGFR, estimated glomerular filtration rate;
GFR, glomerular filtration rate; i.v., intravenous; NCS, non-cardiac surgery.
aClass of recommendation.
bLevel of evidence.
Recommendation Table 31— Recommendations for
management of patients with obesity undergoing non-
cardiac surgery
Recommendations Classa Levelb
It is recommended to assess cardiorespiratory
fitness to estimate peri-operative CV risk in obese
patients, with particular attention to those
undergoing intermediate- and high-risk NCS.565,570
I B
In patients at high risk of obesity hypoventilation
syndrome, additional specialist investigation
before major elective NCS should be
considered.516
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aClass of recommendation.
bLevel of evidence.
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6.13. Diabetes
Due to the progressive ageing of the population undergoing sur-
gical procedures and the increasing prevalence of obesity world-
wide, the prevalence of diabetes among patients undergoing
NCS is expected to increase in years to come.4,571 Several
studies have demonstrated that diabetic patients undergoing
NCS have a higher prevalence of CAD than non-diabetic patients.
Furthermore, patients with diabetes are more likely to have silent
ischaemia because of altered neural pain pathways in the heart.572
For this reason, patients with diabetes appear to have a greater
risk of post-operative myocardial ischaemia. Different reasons ex-
ist behind the relation between DM and increased peri-operative
mortality in patients undergoing NCS. First, patients with diabetes
are known to have more comorbidity and/or advanced CAD at
the time of intervention. Second, diabetes is a clear risk factor
for stroke. Diabetes is associated with post-operative congestive
HF and wound infections. Many patients with diabetes have im-
paired renal function. The presence or a new diagnosis of impaired
glucose metabolism in patients scheduled for NCS should follow
the recommendations provided for the general population in
the 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovas-
cular diseases,573 including increased awareness regarding pos-
sible subclinical organ damage.
The glycated haemoglobin (HbA1c) test should be performed in
all patients with diabetes or impaired glucose metabolism scheduled
for NCS, if this measurement has not been performed in the previ-
ous 3 months. There is evidence to support that pre-admission op-
timal treatment of hyperglycaemia in patients scheduled for elective
NCS is effective in reducing the post-operative risk of CV events, in-
cluding MI, stroke, and progression of HF.574 In contrast, no clear as-
sociation has been shown between intra-operative blood glucose
levels and the subsequent risk of surgical site infection, MI, stroke,
and death in patients undergoing NCS.575 The risk of acidosis asso-
ciated with metformin use is also debated.576 Nevertheless, repeated
blood glucose monitoring on the day of surgery is recommended,
with a general consensus to maintain peri-operative glucose levels
,10.0 mmol/L without causing hypoglycaemia (target level 5.6–
10.0mmol/L). This can be achieved either with subcutaneous doses
of rapid-acting insulin analogues or with i.v. insulin.577 Handling
of SGLT2 inhibitors in relation to surgery has been discussed in
Section 5.2.
6.14. Cancer
Due to their generally older age, cancer patients have a high preva-
lence of CV risk factors and CVD, being a population at increased
risk of adverse events in cases of NCS. It is therefore important to
optimize treatment of CV risk factors and known CVD before
NCS, following the general and disease-specific recommendations
provided in other sections of these guidelines. Furthermore, NCS
may be particularly challenging in cancer patients because of previous
administration of potentially cardiotoxic chemotherapy or fibrosis
due to previous radiation. For example, the widely used anthracy-
clines have a dose-dependent relation with the incidence of HF
and the use of trastuzumab can lead to important cardiotoxicity
and should be taken into account in the pre-operative assessment.
Furthermore, radiation therapy to areas that included the heart
may lead to premature CAD and VHD; previous thoracic radiother-
apy may predispose younger patients to heart disease who would
otherwise not have an elevated risk. Post-operative AF is frequently
observed in patients undergoing cancer surgery, with the highest in-
cidence reported for lung surgery. Patients with cancer are at ele-
vated risk of thrombosis due to both the disease itself and patient-
and treatment-related factors. In a small study of patients undergoing
planned open surgery for abdominal or pelvic cancer, enoxaparin
prophylaxis for 4 weeks compared with 1 week reduced the inci-
dence of thrombosis (4.8% in the enoxaparin group vs.12.0% in
the placebo group; P= 0.02).582 Although later studies have shown
somewhat conflicting results, the consensus is to recommend ex-
tending thromboprophylaxis after major abdominal and/or pelvic
surgery for cancer to 4–5 weeks, with preferred use of LMWH.583
A summary of patient-related and cancer therapy-related factors
that could influence peri-operative risk is shown in Table 15.
Further information is available in the 2022 ESC Guidelines on car-
dio-oncology.584
6.15. Coronavirus disease 2019
Coronavirus disease 2019 (COVID-19) is an infectious disease
caused by the severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2). In a recent observational study, among 140 231 pa-
tients scheduled for NCS, 2.2% of patients had a pre-operative diag-
nosis of SARS-CoV-2 infection.585 Patients undergoing surgery with
peri-operative or recent SARS-CoV-2 appear to be at increased risk
of post-operative VTE and mortality compared with patients with no
history of SARS-CoV-2 infection.586 Furthermore, the possible myo-
cardial injury associated with COVID-19 infection might increase the
Recommendation Table 32— Recommendations for
management of patients with diabetesmellitus under-
going non-cardiac surgery
Recommendations Classa Levelb
In patients with diabetes or disturbed glucose
metabolism, a pre-operative HbA1c test is
recommended, if this measurement has been not
performed in the previous 3 months. In case of
HbA1c ≥8.5% (≥69 mmol/mol), elective NCS
should be postponed, if safe and practical.578–581
I B
Continued
A pre-operative assessment for concomitant
cardiac conditions (see Sections 3 and 4) is
recommended in patients with diabetes with
suspected or known CAD, and those with
autonomic neuropathy, retinopathy, or renal
disease and scheduled to undergo intermediate-
or high-risk NCS.
I C
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CAD, coronary artery disease; HbA1c, glycated haemoglobin; NCS, non-cardiac
surgery.
aClass of recommendation.
bLevel of evidence.
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intrinsic peri-operative risk of adverse cardiac events associated with
surgical procedures.587,588
To date, there is no specific CV screening to be performed after
COVID-19 infection in patients scheduled for NCS. The pre-
operative evaluation of CV risk associated with NCS in this specific
subset of patients should incorporate, beyond the general risk as-
sessment outlined in these guidelines, the severity of COVID-19 dis-
ease, history of CV complications during COVID-19 infection, and
functional capacity after recovery. This information is deemed of im-
portance to further optimize timing of surgery and the treatment of
COVID-19-associated cardiovascular conditions affecting the peri-
operative risk of NCS.589
The optimal timing of NCS in patients with a history of COVID-19
infection is largely unknown. Generally, elective NCS should be post-
poned until complete recovery and optimization of coexisting co-
morbidities. Registry data of patients undergoing NCS after
COVID-19 infection report increased risks of mortality and morbid-
ity up to 7 weeks post-COVID diagnosis.586 Another study has re-
ported greater risk of post-operative complications up to 8 weeks
post-diagnosis.590 However, it should be noted that almost all avail-
able data come from study periods with zero to low prevalence of
vaccination, and no robust data exist on patients recovering from
the more recent Delta and Omicron variants.
A joint statement on elective surgery and anaesthesia for patients
after COVID-19 infection from the American Society of
Anaesthesiologists and Anaesthesia Patient Safety Foundation591
suggests delaying elective surgery for 7 weeks after a SARS-CoV-2
infection in unvaccinated patients who are asymptomatic at the
time of surgery. The clinical course of COVID-19 infection, presence
and intensity of cardiopulmonary symptoms during the acute and
late phases, and pre-existing comorbidities should be taken into con-
sideration. In addition, persistence of COVID-19 symptoms—such
as fatigue, shortness of breath, and chest discomfort—should be gi-
ven attention, as this condition is associated with higher post-
operative mortality independent of the timing of COVID-19 diagno-
sis.588,589 The evidence is currently insufficient to make recommen-
dations for those who become infected after vaccination.
7. Peri-operative monitoring and
anaesthesia
7.1. Peri-operative monitoring
Despite the absence of prospective RCTs investigating the prognos-
tic relevance of peri-operative monitoring, previous evidence clearly
indicates that the routine use of monitoring improves safety of sur-
gical procedures. Mandatory intra-operative monitoring of the CV
and respiratory systems, temperature, neuromuscular transmission,
and depth of anaesthesia is recommended.592,593
Routine CV monitoring includes ECG, automated non-invasive BP
measurement at regular intervals, and peripheral oxygen saturation
with pulse oximetry. Near-infrared spectroscopy has recently been
introduced to assess regional tissue perfusion and oxygenation. In se-
lected cases, more invasive monitoring techniques can be applied
such as continuous arterial BP measurement via an arterial catheter
and monitoring of cardiac output. Mean arterial pressure and heart
Table 15 Factors that could influence peri-operative risk during cancer surgery and preventive strategies
Factors that could influence peri-operative risk during cancer
surgery
Preventive strategies
• Patient-related
factors
• Lifestyle risk factors—smoking, obesity, sedentary lifestyle
• Poorly controlled CV risk factors—hypertension, diabetes
• Pre-existing CVD, including cancer therapy-related cardiovascular
toxicity
• Cardiac medication increasing peri-operative bleeding risk (e.g.
antiplatelets and anticoagulants)
• Historical primary malignancy
• Current cancer type, stage, and location
• Arrhythmias (due to myocardial cancer invasion, induced
QT-prolongation, AF, or imbalance of autonomic nervous system)
• Optimal management of CV risk factors and
CVD
• Optimize preventive strategies with respect
to VTE and arterial thromboembolic events
• ECG monitoring for arrhythmias
• Correction of all proarrhythmic conditions
• Neoadjuvant cancer
therapy
• Previous cardiotoxic cancer treatments (especially anthracycline
chemotherapy and/or trastuzumab; immune checkpoint inhibitors,
VEGFi, fluoropyrimidine and thoracic radiotherapy)
• Cancer treatments increasing peri-operative bleeding risk (e.g.
antiangiogenics, BTKi)
• Cancer treatments increasing risk of arrhythmias
• Ensure optimal CV monitoring of
neoadjuvant therapy
• Optimize preventive strategies with respect
to VTE and arterial thromboembolic events
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AF, atrial fibrillation; BTKi, Bruton tyrosine kinase inhibitors; CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram; VEGFi, vascular endothelial grow factor inhibitor;
VTE, venous thromboembolism.
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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 add-
ition, TEE is increasingly being used as an intra-operative monitoring
technique in major surgery in cardiac compromised patients and dur-
ing cardiac surgery. Decisions on the extent of peri-operative mon-
itoring 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 non-
invasive and easily applicable. Pulse oximetry enables in vivomeasure-
ment of arterial oxygen saturation, and capnometry measures end-
tidal carbon dioxide concentration during inspiration and expiration;
these monitors also provide information about the global haemo-
dynamic status.
Patients, independent of the anaesthetic technique and informa-
tion 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 at-
tention 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 de-
scription. 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 re-
cent 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 ven-
ous system, vasodilatation, and decreased BP. Therefore, mainten-
ance 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 peri-
operative haemodynamics has been recognized for many years.599
In the past few years, several studies have focused on the relation-
ship 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 or-
gan 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 observa-
tional design with a large variability in patient characteristics. In add-
ition, 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 def-
inition described 48 different definitions of intra-operative hypoten-
sion. When applying these definitions to a cohort of 15 509
consecutive adult patients undergoing NCS under general anaesthe-
sia, 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 de-
fine 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 conclu-
sions on reported results remain hazardous. A recent expert con-
sensus 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 correc-
tion of intra-operative hypotension is also associated with improved
post-operative outcome. To date, only one study has specifically ad-
dressed 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 tar-
geting a systolic BP within 10% of the patient’s normal resting value re-
sulted 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 un-
derstanding the underlying mechanisms of intra-operative hypoten-
sion, 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 hypoten-
sive episode. The underlying mechanisms for intra-operative hypo-
tension 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
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A detailed analysis of the strategies for the different chronic CV
medication is discussed in Section 5. Of note, post-operative out-
come is not only negatively influenced by the occurrence of
intra-operative hypotension, but also by hypotensive events during
the initial four post-operative days.603 For adult non-cardiac surgi-
cal patients, there is insufficient evidence to recommend a general
upper limit of arterial pressure at which therapy should be in-
itiated, although pressures .160 mmHg have been associated
with myocardial injury and MI.602
Intra-operative tachycardia may adversely affect the myocar-
dial oxygen balance and thus result in peri-operative myocardial
injury. A retrospective analysis of 41 140 patients found that a
heart rate ≥90 b.p.m. was associated with an increased risk of
myocardial injury.604 These findings were similar to observations
in the Vascular Events in Noncardiac Surgery Patients Cohort
Evaluation (VISION) trial.605 An analysis of high-risk surgical pa-
tients found that an HR .87 b.p.m., recorded at rest before
pre-operative cardiopulmonary exercise testing, was strongly as-
sociated with distinct CV phenotypes, which may explain the unin-
tended, adverse consequences of non-personalized treatments
aimed at reducing intra-operative tachycardia in isolation from other
haemodynamic factors.606 Finally, a recent study evaluated the asso-
ciation between intra-operative tachycardia and a composite of
post-operative myocardial injury and all-cause mortality. The major
finding of this study was the lack of an association between
intra-operative heart rate .90 b.p.m. and the composite outcome;
HR .80 b.p.m. or .100 b.p.m. were also not associated with the
composite outcome.607 Taken together, the assumed association
between intra-operative tachycardia and adverse peri-operative out-
come remains a subject of ongoing controversy. However, it seems
advisable to consider intra-operative tachycardia as an indicator of
haemodynamic impairment.
7.2.2. Choice of anaesthetic agent
The choice of the anaesthetic agent has been considered to be of lit-
tle importance in terms of patient outcome, provided that vital func-
tions are adequately supported. Evidence from surgical myocardial
revascularization studies indicates that a volatile vs. i.v. anaesthetic
regimen is associated with less post-operative troponin release with-
out impact on clinical outcomes.599,608 A recent large multicentre
randomized trial found a neutral effect on 12 month mortality asso-
ciated with volatile vs. i.v. anaesthetic regimen.609 In NCS, incidence
of post-operative cardiac events is not influenced by the choice of a
volatile or an i.v. anaesthetic regimen.610
7.3. Locoregional techniques
The analgesic effects of neuraxial analgesia are well-established. The
main peri-operative indications for epidural analgesia include major
open abdominal surgery and thoracotomy. Possible additional bene-
fits of epidural analgesia, such as accelerated recovery and decreased
post-operative complications, remain a matter of debate.611,612
Neuraxial analgesia may induce sympathetic blockade.When reach-
ing the thoracic dermatome level 4, a reduction in cardiac sympathetic
drive may occur, with subsequent reduction in myocardial contractil-
ity, heart rate, and change in cardiac loading conditions. There are no
studies specifically investigating the changes in outcomes related to
neuraxial anaesthetic techniques in patients with cardiac disease.
Cardiac patients often take various types of drugs that interfere
with coagulation; therefore, care should be taken to ensure sufficient
coagulation ability when neuraxial blocks are applied.613
Define severity:
(i) mean blood pressure decrease >20% from baseline
(ii) the duration of the hypotensive episode
Patients with intra-operative hypotension
Underlying mechanism
Sympathicolysis with
vasodilatation
Hypovolaemia
Other more 
complex causesa
Smooth induction
Avoid ‘too deep’ anaesthesia
positioning (Trendelenburg,
legs up)
Vasoconstriction
(cave organ perfusion)
Advanced diagnosis
Appropriate treatment
Exclude impaired venous return
Restore circulating volume
Figure 16 Pathophysiological approach to address intra-operative hypotension. aE.g. peri-operative myocardial failure.
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Current research is focusing on alternatives for neuraxial analgesia
with similar effects on peri-operative pain control in patients with
cardiac comorbidities undergoing NCS; these include alternative an-
algesic techniques such as i.v. analgesia, continuous wound infiltra-
tion, paravertebral bloc, and selective nerve blocks.
7.4. Peri-operative goal-directed
haemodynamic therapy
Goal-directed therapy aims to optimize CV performance, in order to
achieve normal or even supranormal oxygen delivery to tissues, by
optimizing pre-load and inotropic function using pre-defined haemo-
dynamic targets. In contrast to clinical signs or arterial
pressure-orientated standard therapy, goal-directed therapy is based
on flow or fluid responsiveness of haemodynamic variables, such as
stroke volume, response to fluid challenges, stroke volume or pulse
pressure variation, or similar optimization of cardiac output.
Goal-directed therapy was initially based on the use of a pulmonary
artery catheter. Less-invasive techniques have recently been devel-
oped, including: transoesophageal Doppler, transpulmonary dilution
techniques, and advanced pressure waveform analysis. Early goal-
directed fluid therapy—in the right patient cohort and with a clearly
defined protocol—has been shown to decrease post-operative mor-
tality and morbidity.614–618
7.5. Post-operative management
Several studies have demonstrated that it is possible to stratify the
risk of post-operative complications and mortality with a simple sur-
gical Apgar score. This post-event stratification might enable patients
to be redirected to higher-intensity care units. The importance of
such risk stratification is underscored by the results of the EuSOS
group. In this 7 day cohort study, 46 539 consecutive adult NCS pa-
tients in 498 hospitals across 28 European nations were included:
1855 patients (4%) died before hospital discharge and 1358 (73%)
of those patients were not admitted to critical care at any stage after
surgery.7 This concept of failure-to-rescue has gained a lot of atten-
tion in peri-operative medicine in the last few years and strategies
have been proposed to address this issue.619–622
Severe post-operative pain occurs in 5–10% of patients, increases
sympathetic drive, and delays recovery.623,624 A recent study demon-
strated that time-weighted average pain scores within 72 h after sur-
gery were significantly associated with myocardial injury in patients
undergoing NCS;625 this finding underscores the importance of ef-
fective post-operative analgesia to reduce post-operative CV risk.
The place of non-steroidal anti-inflammatory drugs (NSAIDs) in
the treatment of post-operative pain in cardiac patients undergoing
NCS is a point of debate. Diclofenac has been shown to carry the
highest CV risk of any of the non-selective NSAIDs.626,627 The CV
risk of ibuprofen seems to be comparable with that of celecoxib.628
Naproxen has a better CV safety profile than diclofenac and ibupro-
fen.629,630 One randomized trial found that parecoxib and valdecoxib
did not increase thromboembolic events in patients undergoing
NCS. A meta-analysis of 32 randomized trials did not find an in-
creased CV risk when comparing parecoxib/valdecoxib with pla-
cebo,631 and a single-centre observational study with .10 000
patients undergoing arthroplasty found no association between
NSAID use and post-operative MI.632 In contrast, another
meta-analysis of three randomized trials including 2604 major sur-
gery patients detected a 2.3-fold increase in MACEs in the group
with COX-2 inhibitors. In a position paper, The ESC Working
Group on Cardiovascular Pharmacotherapy advises that non-aspirin
NSAIDs should generally not be used in patients with established or
at high risk of CVD.633
8. Peri-operative cardiovascular
complications
Specific challenges apply to detecting CV complications that occur
peri-operatively. First, due to anaesthesia and analgesia, PMI, which
is the most common CV complication, is largely asymptomatic in
90% of patients and is therefore missed in routine clinical prac-
tice in the absence of surveillance for PMI.41,101,111,413,636–641
Second, post-operative pain, nausea, surgical wounds, and drains
may interfere with the early identification of acute cardiac disor-
ders, such as PMI, Takotsubo syndrome, tachyarrhythmias, and
acute HF. Third, cardiologists are usually not directly involved in
post-operative care; therefore, the early detection and early treat-
ment of cardiac complications is performed by non-cardiologists,
sometimes with little training in the early detection of acute car-
diac disorders. Given the relatively high prevalence of cardiac com-
plications, their high morbidity and mortality, and the availability of
effective therapy, high awareness combined with surveillance for
PMI in high-risk patients (known CAD, PAD, insulin-dependent
DM, or symptoms suggestive of cardiac disorders) undergoing
intermediate- or high-risk NCS is recommended to overcome
Recommendation Table 33— Recommendations for
peri-operative monitoring and anaesthesia
Recommendations Classa Levelb
In order to preserve optimal CV stability, it is
recommended to apply goal-directed
haemodynamic therapy in patients undergoing
high-risk NCS.614–618
I A
It is recommended to avoid post-operative acute
pain.614
I B
In order to minimize the risk of post-operative
organ dysfunction, it is recommended to avoid an
intra-operative mean arterial pressure decrease of
.20% from baseline values or,60–70 mmHg for
≥10 min.214,600–602,634
I B
Non-aspirin NSAIDs are not recommended as
first-line analgesics in patients with established or
high risk of CVD.633,635
III B
©
ES
C
20
22
CV, cardiovascular; CVD, cardiovascular disease; NCS, non-cardiac surgery; NSAID,
non-steroidal anti-inflammatory drug.
aClass of recommendation.
bLevel of evidence.
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these challenges.41,101,109–111,118,413,636–639,642,643 All measures
need to be carefully aligned with the responsible surgeon.
Chronic cardiac disorders, such as CAD, seem to provide a sub-
strate for cardiac complications during and after surgery.41,413,636,637
Several related chronic conditions (e.g. diabetes and renal insuffi-
ciency), which are likely to be surrogates for undiagnosed cardiac dis-
ease, are also strongly associated with peri-operative cardiac
complications (Figure 17).41,413,636,637
Acute conditions such as trauma, surgery, and anaesthesia itself in-
duce activation of the sympathetic nervous system, inflammation,
stress, hypercoagulable, and catabolic states, all of which may trigger
cardiac complications.41,413,636,637 While the risk of CV complica-
tions after NCS is highest in the immediate peri-operative period,
it seems to remain increased for a prolonged ‘vulnerable period’ of
3–5 months.8
8.1. Peri-operative myocardial
infarction/injury
Peri-operative MI (PMI) is defined as acute cardiomyocyte injury
(post-operative hs-cTn T/I release) with or without accompanying
symptoms, and with or without ECG or imaging evidence of acute
myocardial ischaemia. Peri-operative MI can only be reliably and
rapidly detected using PMI surveillance with hs-cTn T/I measure-
ments before and serially after surgery (e.g. 24 and 48 h post-
operatively). In the BASEL-PMI study, circa 15% of patients with
pre-existing CAD/PAD or aged .65 years undergoing major NCS
developed PMI.8 As most PMI occurs during the operation itself or
in the immediate post-operative period, during which high doses
of anaesthetics and/or analgesics are required, 90% of patients
with PMI do not report typical symptoms and are therefore
missed in routine clinical practice.41,101,111,413,636–639 This is of major
concern, as the mortality risk associated with PMI is also high in
patients without symptoms.41,101,111,413,636–639 Similarly, the
mortality risk associated with PMI is high in patients without add-
itional ECG and/or imaging evidence of myocardial ischae-
mia.8,41,101,109–111,118,413,564,636–639,641 Overall, 30 day mortality in
patients developing PMI is 10%.8,41,101,109–111,118,413,564,636–639,641
No single intervention has yet been proven to be unequivocally
beneficial in the prevention of PMI.185,644
It is important to highlight that PMI is not a homogenous disease.
Several different pathophysiologies and clinical phenotypes may
underlie PMI (Figure 18). At least one additional criterion (ischaemic
pain; ischaemic ECG changes; imaging evidence of new loss of viable
myocardium, or new regional wall motion abnormality in a pattern
consistent with an ischaemic aetiology; and thrombus in coronary
Patient-related factors
Procedure-related factors (surgery and anaesthesia):
Factors associated with peri-operative cardiovascular complications
Urgency of the procedure, hypotension, hypercoagulability,
bleeding inflammation, tachycardia, hypothermia, SNS stimulation
Post-operative factors:
Hypotension, bleeding,
hypoxaemia, tachycardia, pain
Cardiovascular complications:
Type 1 myocardial infarction
Type 2 myocardial infarction
Acute heart failure, arrhythmias
Pulmonary embolism
Stroke
Cardiovascular death
Chronic:
Age >75 years
Coronary artery disease
Heart failure
Severe aortic stenosis
Peripheral arterial disease
Cerebrovascular disease
Renal insufficiency
Diabetes, anaemia
(Sub)-Acute:
Acute coronary syndrome
Acute aortic syndrome
Acute stroke
Acute trauma (e.g. hip fracture)
Figure 17 Factors associated with peri-operative cardiovascular complications. SNS, sympathetic nervous system.
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angiography) is required for patients with PMI to also meet the def-
inition of peri-operative myocardial infarction, according to the
fourth universal definition.643 Because is often initially unclear
whether the patient will end up fulfilling the criteria for peri-
operative myocardial infarction, the broad term PMI is preferred in
the initial assessment. In order to properly interpret the aetiology
of elevated post-operative hs-cTn T/I concentrations, a baseline pre-
operative concentration is necessary to determine whether the in-
crease is acute or chronic (see Section 4).643 To identify the under-
lying pathophysiology and define causal therapy, systematic
work-up and early differentiation of primarily non-cardiac causes
(e.g. severe sepsis, PE) vs. the different cardiac causes—including
type-1 MI, type-2 MI, tachyarrhythmia, and acute HF—is of major im-
portance (Figures 18 and 19). Transthoracic echocardiography is
helpful in the work-up of most patients with PMI.
The term myocardial injury following NCS (MINS) has been used
for a selected subset of patients with cardiac PMI, in whom cardio-
myocyte injury was deemed most likely due to CADwith myocardial
ischaemia (i.e. secondary to supply–demand mismatch or throm-
bosis), in the absence of an atypical surgical physiological stress,
and no evidence of a cardiac non-CAD aetiology, e.g. rapid AF, acute
HF).101,109,638,641,642,645,646 In approximately half of all patients with
PMI, the underlying pathophysiology cannot be reliably ascertained
based on the commonly available documentation and is assumed
to be likely type-2 MI due to undocumented or relative hypotension,
but may also include missed type-1 MI, or missed PE in cases in which
CT angiography has not yet been performed post-operatively.110,647
It is therefore important to highlight that PMI surveillance also facil-
itates the detection of primarily non-cardiac disorders with immedi-
ate therapeutic consequences, such as PE, that would otherwise have
been missed.
The prevalence of PMI depends on patient-related, procedural-
related, and post-operative factors, and the required minimum extent
of acute myocardial injury, quantified by absolute increase in
hs-cTn T/I (e.g. the 99th percentile ULN) above the pre-operative
hs-cTn T/I concentration.8,41,101,109–111,118,413,564,636–639,641,648
Cardiac troponin
Chronic cardiac troponin Acute cardiac troponin = PMI
Primarily
non-cardiac
cause
Cardiac cause
Severe sepsis
Pulmonary embolism
Stroke
Athero-
thrombosis
Type 1 MI Type 2 MI
Supply demand
mismatch with
obvious type 2
trigger
(hypotension,
anaemia)
Tachy-
arrhythmia
Supply demand
mismatch
Acute heart
failure
Multiple
mechanisms
Likely
type 2 MI
Missed
type 1 MI
Undocumented
hypotension
Mild
hypotension
Day 1 or 2 after the NCS
CK
cTn T
cTn l
Myocardial injury
Figure 18 Differential diagnosis of elevated post-operative cardiac troponin concentrations. CK, creatinine kinase; cTn l, cardiac troponin I; cTn T,
cardiac troponin T; MI, myocardial infarction; PMI, peri-operative myocardial infarction/injury. Please be aware that the accuracy of physicians’ judgement
in the classification of type-1 vs. type-2 MI in the peri-operative setting may be lower vs. the non-operative setting.647
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An absolute increase in more than the ULN above pre-operative
concentrations has consistently been shown to be associated with
a relevant increase in 30 day and long-termmortality, and other non-
fatal post-operative cardiac complications, and can easily be
determined for each hs-cTn T/I assay. This threshold is therefore
recommended for clinical use.8,41,101,109–111,118,413,564,636–639,641,648
However, further studies are warranted regarding optimal thresh-
olds. Emerging data suggest that surveillance for PMI is
cost-effective.117,119
Identification of the most likely pathophysiology is critical for se-
lection of the most appropriate therapy. Evidence from a large single-
centre retrospective cohort suggests that involvement of a cardiolo-
gist in the work-up and therapy of these patients was associated with
lower mortality.649 Mortality substantially differs among the different
phenotypes: 30 day all-cause mortality and the composite of 30 day
CV death, life-threatening arrhythmia, acute MI occurring after day 3,
and cardiac decompensation are highest in patients with acute HF
and primarily extra-cardiac PMI, such as severe sepsis or PE, inter-
mediate for type-1 MI and tachyarrhythmias, and modestly elevated
in likely type-2 MI.110 Type-2 MI patients are usually treated as for
type-1 MI, although the evidence for this is limited.
In a randomized, placebo-controlled trial, 1754 patients (mean age
70 years) who had developed MINS after NCS (mainly orthopaedic,
general, and vascular surgery) were randomly assigned (1:1) to re-
ceive dabigatran 110 mg orally b.i.d. or matched placebo within 35
days of MINS;650 60% of patients were already on aspirin or a
N
N
Y
Y
Y
ST or ST or
typical chest pain
Other cardiac cause
Transthoracic
echocardiography
N
N
N
Relative or
undocumented
hypotensionb
Severe anaemiaa Type 2 MI
Systematic work-up and treatment of peri-operative myocardial injury/infarction
12-lead ECG, symptoms, and haemoglobin
Immediate transfusion
followed by
reassessment for ICA
Aspirin,d statin,
stress imaging/CCTA/ICA
Y
Y
Severe anaemiaa
(Hb <80 g/L)
Severe (documented)
hypotensionb
Type 2 MI
Step 5
Step 4
Step 3
Step 2
Step 1
Type 1 MI
Tachyarrhythmia (type 2 MI)
Acute heart failure (injury)
Aortic valve stenosis (injury)
Y Sepsis, pulmonary embolism, stroke (injury)
ICA, aspirin,c
statin, monitoring
(Class I)
Treat cause
Treat cause
Treat cause
Non-cardiac cause
Type 2 MI or missed type 1 MI
Figure 19 Systematic work-up (aetiology) and therapy of peri-operative myocardial infarction/injury. CCTA, coronary computed tomography angi-
ography; ECG, electrocardiogram; Hb, haemoglobin; ICA, invasive coronary angiography; MI, myocardial infarction; N, no; ST, ST-segment. Y, yes;
Most patients with type-2 MI and silent type-1 MI should be scheduled for stress imaging or CCTA/ICA as outpatients after discharge, depending on
symptoms prior to or after surgery and known CAD. aOr active bleeding. bOr other type-2 MI trigger such as hypoxaemia, tachycardia, hypertension.
cDual antiplatelet therapy after coronary stenting. dPossibly in combination with dabigatran 110 mg b.i.d.
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P2Y12 inhibitor. The median peak measured hs-cTn concentration
associated with the diagnosis of MINS was 82 ng/L. More than
90% of MINS events occurred without a clinical symptom or sign
of cardiac ischaemia. Dabigatran/placebo was initiated a median of
6 days after the operation and the average time on study drug was
9 months. Among patients with MINS randomly assigned to re-
ceive dabigatran (n= 877) or placebo (n= 877), the composite pri-
mary efficacy outcome of a major vascular complication—including
vascular mortality, MI, non-haemorrhagic stroke, peripheral arterial
thrombosis, amputation, and symptomatic VTE—occurred in fewer
patients randomized to dabigatran than placebo (97 [11%] of 877 pa-
tients assigned to dabigatran vs. 133 [15%] of 877 patients assigned
to placebo; HR, 0.72; 95% CI, 0.55–0.93; P= 0.0115). There was
no increase in major bleeding. Based on these data, in patients with
MINS and at low risk of bleeding, initiation of dabigatran 110 mg or-
ally b.i.d. may be considered about 1 week after NCS.
8.2. Spontaneous myocardial infarction
(after day 2)
The incidence of post-operative spontaneousMI after day 2 seems to be
about 0.5%within 30 days, and 1–2%within 365 days for patients under-
going major NCS with established CAD, PAD, or aged .65 years.8
In the immediate post-operative period (,5 days), bleeding is a ma-
jor concern and limits the use of antiplatelet and anticoagulant ther-
apy, depending on the site and extent of surgery. Otherwise, the
same principles as for MI therapy should generally be applied follow-
ing the recommendations of speciality guidelines.98,171
8.3. Takotsubo syndrome
The incidence of peri-operative Takotsubo syndrome remains un-
known, as none of the studies with PMI screening used echocardiog-
raphy in all patients during PMI work-up. Increased awareness in the
non-operative setting has led to a substantial increase in the detec-
tion of Takotsubo syndrome, and the use of TTE in the work-up
of PMI is strongly encouraged. Anecdotal evidence suggests that it
is likely that the incidence is also higher than expected in the peri-
operative setting.8,41,101,109–111,118,413,564,636–639,641,644
8.4. Acute heart failure
The incidence of post-operative acute HF seems to be 1–2% within
30 days and 4–6% within 365 days in patients with established CAD,
PAD, or aged .65 years undergoing major NCS.8 Pre-existing diag-
nosed or undiagnosed chronic HF and volume loading in the peri-
operative and post-operative periods are important contributors.
In the absence of studies specifically investigating acute HF post-
operatively, the general principles of acute HF diagnostic work-up
and therapy should be applied.651
8.5. Venous thromboembolism
The incidence of VTE in the peri-operative phase is currently un-
known and likely underreported due to the lack of systematic
screening methods and the limited validity of diagnostic tools (e.g.
D-dimer, typical pain symptoms) in this setting. It is associated
with high peri-operative mortality (17%).322 Risk factors for post-
operative VTE/PE include type of surgery (e.g. high-risk hip arthro-
plasty, open prostatectomy, open surgery for malignancy), acute
renal insufficiency, MI, and post-operative infection.322
Stratification of the extent of embolism (e.g. massive, submassive,
and subsegmental; high risk, intermediate high/low risk, and low
risk) is important to predict mortality and guide therapeutic strat-
egy.652 Pulmonary embolism should be suspected in patients with
PMI without a clear cause. Close haemodynamic monitoring and
monitoring of RV function (echocardiography, CT) is essential to de-
termine which PE patients require aggressive therapy. There is cur-
rently a lack of evidence regarding adequate antithrombotic therapy
in patients with post-operative PE, since recent major surgery or
trauma was a contraindication in previous trials of thrombolytic or
anticoagulant therapy.653 Small case series support the use of sys-
temic thrombolysis, surgical thrombectomy,654 or catheter-directed
therapies in massive PE. In general, anticoagulation, preferably
LMWH or fondaparinux, should be initiated as early as possible.652
Oral anticoalgulant therapy, preferably NOAC due to the lower
bleeding risk, should be initiated, depending on post-operative renal
function and bleeding risk, as early as possible for at least 3
months.652
Rescue thrombolytic therapy is recommended for patients with
PE and haemodynamic deterioration on anticoagulation treatment
in the post-operative phase, if possible, according to bleeding
risk.652 As an alternative to thrombolytic therapy for massive PE, sur-
gical embolectomy or percutaneous catheter-directed treatment
should be considered for patients with haemodynamic deterioration
on anticoagulation treatment, particularly in patients with high bleed-
ing risk.
8.6. Atrial fibrillation and other relevant
arrhythmias
Post-operative AF is defined as new-onset AF in the immediate post-
operative period; its incidence ranges between 2–30%, with peak in-
cidence 2–4 days post-operatively.655,656
Although many post-operative AF episodes are self–terminating
and some are asymptomatic, post-operative AF has been associated
with a four- to five-fold risk of AF recurrence in the 5 years following
cardiac surgery, while the risk of recurrence after NCS is less well de-
scribed.656–660 Importantly, post-operative AF is a risk factor for
stroke, MI, and death compared with non-post-operative AF pa-
tients.656,658,661 Post-operative AF may also lead to haemodynamic
instability, prolonged hospital stay, infections, renal complications,
bleeding, increased in-hospital death, and greater healthcare
costs.662–664 The essential principles of the prevention and manage-
ment of post-operative AF are outlined in Figure 20.
8.6.1. Prevention of post-operative atrial
fibrillation
Pre-operative use of beta-blockers is associated with reduced in-
cidence of post-operative AF,204,665–667 but not major adverse
events such as death, stroke, or AKI.668 Importantly, in a large
RCT, peri-operative metoprolol was associated with increased
mortality risk.185 In a meta-analysis, amiodarone (oral or i.v.)
was equally effective in reducing post-operative AF as beta-
blockers,207 whereas their combination was better than beta-
blockers alone.208 Lower cumulative doses of amiodarone
(,3000 mg) may be effective, with fewer adverse events.669–671
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Data for other interventions—such as statins,672,673 magnesium,674
sotalol,666 colchicine,675 or corticosteroids676—are not robust.677,678
8.6.2. Management of post-operative atrial
fibrillation
8.6.2.1. Rate and/or rhythm control
In haemodynamically unstable patients with post-operative AF, an
emergent electrical or possibly pharmacological (i.e. i.v. administra-
tion of amiodarone666 or vernakalant,679 if consistent with the clinical
situation) cardioversion is indicated.99 In haemodynamically stable
patients with post-operative AF, ensuring optimal ventricular rate
control during the arrhythmia is mandatory (using, for example beta-
blockers or verapamil, as needed). As post-operative AF is often self-
terminating, non–emergent cardioversion may not be needed. If
performed in patients with AF lasting ≥48 h, non-emergency cardi-
oversion of post-operative AF should follow the principles of peri-
cardioversion thromboprophylaxis (that is, can be performed only
after the left atrial thrombosis is excluded by TEE or postponed
for 3 weeks of therapeutic OAC therapy). Of note, a RCT of patients
with post-operative AF after cardiac surgery showed no net clinical
N
N
Y
Y
Symptomatic or
difficult rate control
Systemic
anticoagulationa
Haemodynamic
instability
Emergency
cardioversion
Rhythm control
(electrical or
pharmacological
cardioversion)
Management of patients with intra- and post-operative AF
AADs (optional)
Normal LVEF:
Class I or III 
Reduced LVEF:
Amiodarone
Rate control | Target
resting HR <110 b.p.m.
Preserved LVEF:
beta-blocker, CCB
and/or digoxinb
Reduced LVEF:
beta-blocker
and/or digoxinb
Pre-operative 
prevention of AF
Peri-operatively
Discharge
Optimize fluid balance, oxygenation, and pain control 
Minimize inotropes and vasopressors 
Continue pre-operative pharmacological prophylaxis
Pharmacological AF prophylaxis:
Continue beta-blockers (if chronic therapy)
Other AADs in selected patients
Optimize haemodynamics 
Correct electrolyte imbalance 
Identify patients at increased risk for post-operative AF
Individualized follow-up planc
Re-assessment for rhythm and AADs
Long-term OAC in patients at risk of stroke (balanced with bleeding risk)
considering the anticipated net clinical benefit of OAC and informed patient preferences
(Class IIa)
Figure 20 Prevention and management of post-operative atrial fibrillation. AAD, antiarrhythmic drug; AF, atrial fibrillation; b.p.m., beats per minute;
CCB, calcium channel blocker; HR, heart rate; LVEF, left ventricular ejection fraction. N, no; Y, yes. aDepending on the CHA2DS2VASC-score, and post-
operative bleeding risk. bIn the acute post-operative phase, unless blood pressure is high, combination of low-dose beta-blocker and loading with digoxin is
preferred to avoid hypotension. cShould include a cardiology visit before month 3. Adapted from the 2020 ESC Guidelines on the Diagnosis and
Management of Atrial Fibrillation.99
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advantage of rhythm (i.e. achieving and maintenance of sinus rhythm)
vs. rate control strategy.680 Therefore, rate or rhythm control treat-
ment decisions in patients with haemodynamically stable post-
operative AF should be based on patient’s symptoms and shared in-
formed treatment decision-making.99
8.6.2.2. Prevention of atrial fibrillation-related thromboembolic
complications
In all patients with post-operative AF, it should be considered to ini-
tiate therapeutic anticoagulation as soon as possible during in-
hospital treatment, depending on the individual stroke risk
(CHA2DS2-VASc) and the bleeding risk after surgery. In a large
meta-analysis, patients with post-operative AF had 62% higher risk
of early stroke and 37% higher risk of long-term stroke compared
with patients without post-operative AF (long-term stroke rates
were 2.4% in post-operative AF vs. 0.4% in patients without AF),
and a 44% and 37% higher risk of early and long-term mortality, re-
spectively.661 Importantly, post-operative AF was more strongly as-
sociated with the long-term stroke risk in patients undergoing NCS
(HR, 2.00; 95% CI, 1.70–2.35) than in patients undergoing cardiac
surgery (HR, 1.20; 95% CI, 1.07–1.34; P, 0.0001).661
Evidence on the effects of long-term OAC therapy for the pre-
vention of stroke or systemic embolism in patients with post-
operative AF is from observational studies.664,681–685 In a recent
study, post-operative AF following NCS was associated with simi-
lar long-term thromboembolic risk as common, non-surgical AF,
and OAC use was associated with comparable lower risk of
thromboembolism and all–cause mortality in both groups (mean
CHA2DS2-VASc-score 3.0 + 1.7).
686
Based on the available evidence, long-termOAC should be consid-
ered in all patients with post-operative AF at risk of stroke. If antic-
oagulation is parenterally initiated, LMWH or fondaparinux is
recommended (over UFH) for most patients. Non-vitamin K antag-
onist oral anticoagulants should be preferred over VKA for long-
term treatment. Re-evaluation of the continuation of OAC may be
performed after a period of 3 months. A small RCT (ASPIRE-AF;
NCT03968393) on the optimal long-termOAC use among NCS pa-
tients developing post-operative AF is ongoing.
8.7. Peri-operative stroke
With respect to NCS, peri-operative stroke has been reported in
0.08–0.70% of patients undergoing general surgery, 0.2–0.9% of pa-
tients requiring orthopaedic surgery, 0.6–0.9% of lung operations,
and 0.8–3.0% of surgeries involving the peripheral vasculature.687,688
The associated mortality ranges from 18–26%.687,688 A more recent
analysis of 523 059 patients undergoing NCS reported a lower inci-
dence of peri-operative stroke (0.1%), although the occurrence of
this adverse event was associated with an eight-fold increase in peri-
operative mortality within 30 days, corresponding to an absolute risk
increase of .20%.689 Peri-operative stroke is mainly ischaemic or
cardioembolic, and AF is often the leading underlying condition.
Triggers include withdrawal of anticoagulation and the hypercoagul-
able state related to surgery. Additional aetiologies include ather-
oembolism, originating from the aorta or the supra-aortic vessels,
and local atherothrombosis in the presence of intracranial small ves-
sel disease. Hypoperfusion—related to peri-operative arterial
hypotension and/or severe stenosis of the cervicocranial vessels—
is an unusual cause of peri-operative stroke.690 Rarely, peri-operative
stroke may be due to air, fat, or paradoxical embolisms.
In an attempt to attenuate the risk of peri-operative stroke, anti-
platelet/anticoagulant treatments should be continued whenever
possible throughout the peri-operative period. Alternatively, the
period of drug withdrawal should be kept as short as possible, while
weighting thromboembolic and haemorrhagic risks (see Section 5.2).
Adequate selection of the anaesthetic technique (regional vs. neurax-
ial vs. general anaesthesia), prevention and treatment of AF, euglycae-
mic control (avoiding both hyperglycaemia and hypoglycaemia), and
meticulous peri-operative control of BP may all contribute to redu-
cing the risk of peri-operative stroke.
If post-operative stroke occurs, it must trigger immediate action:
angio-CT and neurology/neurosurgical consultation with the goal
to restore flow in the case of acute thrombotic occlusion.
Recommendation Table 34— Recommendations for
peri-operative cardiovascular complications
Recommendations Classa Levelb
It is recommended to have high awareness of
peri-operative CV complications, combined with
surveillance for PMI in patients undergoing
intermediate- or high-risk NCS.41,101,109–
111,118,413,636–639
I B
Systematic PMI work-up is recommended to
identify the underlying pathophysiology and define
therapy.41,101,109–111,118,413,636–639
I B
It is recommended to treat post-operative STEMI,
NSTE-ACS, acute HF, and tachyarrhythmias in
accordance with guidelines for the non-surgical
setting, after interdisciplinary discussion with the
surgeon about bleeding risk.98,99,171,651,652
I C
In patients with post-operative PE of high or
intermediate clinical probability, initiation of
anticoagulation is recommended without delay,
while diagnostic work-up is in progress, if bleeding
risk is low.650,652
I C
Post-operative oral anticoagulation for PE is
recommended to be administered for a period of
at least 3 months.99,650
I C
In patients with a post-operative indication for
OAC, NOAC is generally recommended over
VKA.99
I A
In patients with post-operative AF after NCS,
long-term OAC therapy should be considered in
all patients at risk of stroke, considering the
anticipated net clinical benefit of OAC therapy,
and informed patient preferences.99,682,683,685,686
IIa B
In patients with MINS and at low risk of bleeding,
treatment with dabigatran 110 mg orally b.i.d.may
be considered from 1 week after NCS.650
IIb B
Continued
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9. Key messages
• The occurrence of CV complications in the peri-operative phase
of NCS has a dramatic impact on prognosis.
• The risk of CV complications in patients undergoing NCS is deter-
mined by patient-related factors, type of surgery or procedure, and
the circumstances under which surgery takes place (elective vs. emer-
gency procedure; local or tertiary hospital).
• Specific patient-related risk factors may be reduced by adequate
pre-operative risk assessment and initiation of effective risk-reduction
strategies.
• The quantification of surgical risk as low, intermediate, and high is
helpful in identifying the group of patients who should most benefit
from preventive, diagnostic, and therapeutic approaches to con-
comitant CV conditions.
• Proper selection of type and timing of the surgical procedure may
reduce the risk of complications.
• It is important that patients’ values, quality of life, and preferences
regarding the benefits and risks of surgery are taken into consider-
ation, and that well-informed patients are involved in the decisions.
Risk should be communicated to the patient in absolute terms (e.g.
1 out of 100).
• Clinical examination, patient-reported functional capacity, and
non-invasive tests represent the cornerstone of pre-operative car-
diac assessment.
• Instrumental and functional cardiac examination tools should be
selected in view of the surgical risk, relative diagnostic proficiency,
and healthcare resource utilization and costs.
• The peri-operative evaluation of elderly patients who require
elective major NCS should include frailty screening, which has pro-
ven to be an excellent predictor of unfavourable health outcomes
in the older surgical population.
• Treatment of pre-existing or newly diagnosed CV conditions (e.g.
coronary and peripheral vascular disease, rhythm disorders, and
HF) should be individualized according to the pre-operative risk
of NCS, and considering the recommendations of speciality
guidelines.
• A multidisciplinary approach to evaluate whether the treatment
of concomitant cardiac conditions before scheduled NCS im-
proves peri-operative safety without unnecessary delay is
encouraged.
• Efficient peri-operative management of antithrombotic therapies
in patients scheduled for NCS aims to offer the potential benefit
of preventing thrombotic events without excessive bleeding
complications.
• It is important to clearly and concisely communicate with patients,
with simple verbal and written instructions, about changes in medi-
cation in the pre- and post-operative phases.
• Management in the peri-operative phase of NCS aims to avoid
haemodynamic imbalance, while ensuring sufficient cardioprotec-
tive action.
• Healthcare providers are recommended to have high awareness of
peri-operative CV complications combined with surveillance for
PMI in high-risk patients undergoing intermediate- or high-risk
NCS.
• Routine assessment of treatment quality through specific indica-
tors is important to document and measure the success of pre-
ventive and therapeutic strategies in patients undergoing NCS.
10. Gaps in evidence
• The age cut-off for individuals (considered to be cardiovascularly
healthy) benefiting from risk stratification work-out before NCS
needs to be evaluated.
• Further studies are needed to characterize outcome differences in
NCS between men and women, and between different countries,
in order to individualize peri-operative management and improve
patient safety.
• Evidence on the additive value of cardiac biomarkers, hand-held
ultrasound, problem FOCUS, and stress echocardiography for car-
diac risk stratification of patients scheduled for NCS presenting
with previously unknown cardiac murmur, dyspnoea, oedema,
and chest pain is still lacking. The impact of FOCUS on outcomes
of urgent or time-sensitive surgery needs further investigation.
• The impact of stress imaging (echocardiography or MRI) before
NCS on reduction of peri-operative CV complications in non-
ischaemic heart diseases needs further research.
• The role of right heart catheterization in patients with advanced
HF or patients with severe pulmonary hypertension undergoing
NCS is unknown.
• It is unknown whether artificial intelligence-based systems facilitate
prompt detection and response to imminent adverse events in
high-risk cardiac patients undergoing high-risk NCS.
• Systematic and structured research to investigate pathophysi-
ology, causes, and time distribution of serious peri-operative ar-
rhythmic events among patients undergoing NCS is still needed.
• Strategies for timing of pre-operative CIED control dependent on
device type, urgency, and type of NCS, and risk of EMI during NCS
need to be developed to ensure maximal patient safety.
• Benefit of routine myocardial revascularization of high-risk CCS
patients (except left main or three-vessel CAD, reduced LV func-
tion) before elective intermediate- and high-risk NCS is not
well-established.
• More evidence regarding the need for bridging of anticoagulation
in patients with MHVs is needed.
• There is a lack of evidence regarding the optimal strategies before
emergent or time-sensitive NCS for patients on antithrombotic
treatment at high risk of thromboembolic events, including the:
(i) use of extracorporeal haemoperfusion or NOAC antidotes
(ongoing trial NCT04233073); (ii) use of albumin, extracorporeal
haemoperfusion, or PB2452-specific antidote to antagonized tica-
grelor (ongoing trial NCT04286438 for PB2452); and (iii)
Routine use of beta-blocker for the prevention of
post-operative AF in patients undergoing NCS is
not recommended.185,201
III B
©
ES
C
20
22
AF, atrial fibrillation; b.i.d., twice a day; CV, cardiovascular; HF, heart failure; MI,
myocardial infarction; MINS, myocardial injury following non-cardiac surgery; NCS,
non-cardiac surgery; NOAC, non-vitamin K antagonist oral anticoagulant; NSTE-ACS,
non-ST-elevation acute coronary syndrome; OAC, oral anticoagulant; PE, pulmonary
embolism; PMI, peri-operative myocardial infarction/injury; STEMI, ST-segment
elevation myocardial infarction; VKA, vitamin K antagonist.
aClass of recommendation.
bLevel of evidence.
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premature cessation or bridging during interruption of oral
P2Y12-receptor inhibitors (glycoprotein IIb/IIIa receptor inhibitors
or cangrelor).
• There is lack of well-powered studies to evaluate the role of plate-
let function testing to guide the strategy for treatment of NCS pa-
tients on antiplatelet therapy.
• Evidence regarding the need for and benefit of anticoagulation in
NCS patients with post-operative AF is still lacking (ongoing
ASPIRE-AF trial: NCT03968393).
• Prophylactic strategies to reduce the incidence of post-operative
AF in NCS patients additional to beta-blocker maintenance in pa-
tients already on this treatment need to be evaluated.
• The optimal cardiac work-up and therapy for patients with PMI
within and outside hospital settings need to be evaluated.
• Studies are needed to investigate the impact of the treatment of
peri-operative hypotension on post-operative outcomes, the use
of new HF drug classes (SGLT2 inhibitors and vericiguat), and
the use of NSAIDs as a temporary treatment for acute post-
operative pain.
• Prospective studies are needed to investigate the incremental value
of anaemia algorithms and blood-sparing strategies (use of blood-
sparing blood tubes) to reduce the risk of anaemia-associated ad-
verse outcomes among CV patients undergoing NCS.
11. Sex differences
Sex and gender may significantly affect the management and out-
comes of patients with specific diseases undergoing NCS. There
are sex- and gender-dependent clinical phenotypes of comorbidities
and risk factors, which may have an impact on peri-operative mor-
bidity and mortality. However, there is a paucity of data specifically
addressing the interplay between sex, age, and comorbidities in pa-
tients scheduled for NCS.
The pre-operative assessment before NCS might take sex into
consideration, since the age-adjusted incidence of CVD is lower in
women than men, and the risk of undetected disease could therefore
be lower in women. However, no data exist on sex-specific assess-
ment strategies.
The in-hospital mortality during surgery was recently reported to
be lower in women than men.41,691 In contrast, among 609 735 pa-
tients who underwent elective NCS between 2009 and 2016, the
odds of post-operative 90 day mortality were higher among women
with HF than men with HF.692 Further studies are needed to provide
more information about outcome differences between men and wo-
men in NCS.
Some studies have reported a higher risk of bleeding in women
than men, but other studies could not confirm this. No trials have
systematically investigated the impact of sex differences regarding ef-
ficacy and safety of continuation vs. interruption of antithrombotic
therapy in patients undergoing NCS.
The prevalence of anaemia in women of reproductive age is as high
as 30% (WHO Global Anaemia estimates),693 resulting in millions of
women undergoing surgery every year despite pre-operative anaemia.
Furthermore, since women have lower blood volumes and lower
haemoglobin values than men, but face the same surgical blood loss
as men, they are exposed to far higher risk of post-operative compli-
cations. Also, higher transfusion rates and volumes have been re-
ported in women compared with men in elective surgery.694 It is
therefore of particular importance that clinicians follow the Patient
Blood Management program in women undergoing NCS. Other sex-
related differences in physiology, and pharmacokinetics and pharma-
codynamics of anaesthetic drugs may influence the anaesthesia plan,
pain management, post-operative recovery, and patient satisfaction.
Sex differences regarding presentation, electrophysiological sub-
strate, complications, or long-term outcomes have been reported
in patients undergoing CIED implantation,695,696 and female sex is
a well-known risk factor for stroke in patients with AF.697
However, no specific data exist that suggest sex differences in risk
profile or outcomes of patients with CIEDs or arrhythmias who
undergo NCS.
12. ‘What to do’ and ‘what not to do’ messages from the Guidelines
Recommendations Classa Levelb
Recommendations for clinical risk evaluation
In all patients scheduled for NCS, an accurate history and clinical examination are recommended. I C
It is recommended to perform a pre-operative risk assessment, ideally at the same time as the NCS is proposed. I B
If time allows, it is recommended to optimize guideline-recommended treatment of CVD and CV risk factors before NCS. I C
In patients with a family history of genetic cardiomyopathy, it is recommended to perform an ECG and TTE before NCS, regardless of
age and symptoms.
I C
In patients with a newly detected murmur and symptoms or signs of CVD, TTE is recommended before NCS. I C
In patients with a newly detected murmur suggesting clinically significant pathology, TTE is recommended before high-risk NCS. I C
Continued
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If a patient scheduled for elective NCS has chest pain or other symptoms suggestive of undetected CAD, further diagnostic work-up
before NCS is recommended.
I C
If a patient in need of acute NCS also has chest pain or other symptoms suggestive of undetected CAD, a multidisciplinary assessment
approach is recommended to choose the treatment with lowest total risk for the patient.
I C
In patients with dyspnoea and/or peripheral oedema, an ECG and an NT-proBNP/BNP test is indicated before NCS, unless there is a
certain non-cardiac explanation.
I C
In patients with dyspnoea and/or peripheral oedema and elevated NT-proBNP/BNP, TTE is recommended before NCS. I C
Recommendations for patient information
It is recommended to give patients individualized instructions for pre-operative and post-operative changes in medication, in verbal and
written formats with clear and concise directions.
I C
Recommendations for use of risk assessment tools
In patients who have known CVD or CV risk factors (including age ≥65 years), or symptoms or signs suggestive of CVD it is
recommended to obtain a pre-operative 12-lead ECG before intermediate- and high-risk NCS.
I C
In patients who have known CVD, CV risk factors (including age ≥65 years), or symptoms suggestive of CVD it is recommended to
measure hs-cTn T or hs-cTn I before intermediate- and high-risk NCS, and at 24 h and 48 h afterwards.
I B
TTE is recommended in patients with poor functional capacity and/or high NT-proBNP/BNP, or if murmurs are detected before
high-risk NCS, in order to undertake risk-reduction strategies.
I B
Stress imaging is recommended before high-risk elective NCS in patients with poor functional capacity and high likelihood of CAD or
high clinical risk.
I B
It is recommended to use the same indications for ICA and revascularization pre-operatively as in the non-surgical setting. I C
In low-risk patients undergoing low- and intermediate-risk NCS, it is not recommended to routinely obtain pre-operative ECG, hs-cTn
T/I, or BNP/NT-proBNP concentrations.
III B
Routine pre-operative evaluation of LV function is not recommended. III C
Stress imaging is not recommended routinely before NCS. III C
Routine pre-operative ICA is not recommended in stable CCS patients undergoing low- and intermediate-risk NCS. III C
Recommendations for CV risk factors and lifestyle interventions
Smoking cessation .4 weeks before NCS is recommended to reduce post-operative complications and mortality. I B
Control of CV risk factors—including blood pressure, dyslipidaemia, and diabetes—is recommended before NCS. I B
Recommendations for pharmacological risk-reduction strategies
Beta-blockers
Peri-operative continuation of beta-blockers is recommended in patients currently receiving this medication. I B
Routine initiation of beta-blocker peri-operatively is not recommended. III A
Statins
In patients already on statins, it is recommended to continue statins during the peri-operative period. I B
Recommendations for peri-operative handling of antithrombotic agents
Antiplatelets
It is recommended to delay elective NCS until 6 months after elective PCI and 12 months after an ACS. I A
After elective PCI, it is recommended to delay time-sensitive NCS until a minimum of 1 month of DAPT treatment has been given. I B
In patients with a recent PCI scheduled for NCS, it is recommended that management of antiplatelet therapy is discussed between the
surgeon, anaesthesiologist, and cardiologist.
I C
Continued
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In patients with a previous PCI, it is recommended to continue aspirin peri-operatively if the bleeding risk allows. I B
If interruption of P2Y12 inhibitor is indicated, it is recommended to withhold ticagrelor for 3–5 days, clopidogrel for 5 days, and prasugrel
for 7 days prior to NCS.
I B
For patients undergoing high bleeding risk surgery (e.g. intracranial, spinal neurosurgery, or vitroretinal eye surgery), it is recommended
to interrupt aspirin for at least 7 days pre-operatively.
I C
If antiplatelet therapy has been interrupted before a surgical procedure, it is recommended to restart therapy as soon as possible (within
48 h) post-surgery, according to interdisciplinary risk assessment.
I C
Oral anticoagulants
When an urgent surgical intervention is required, it is recommended that NOAC therapy is immediately interrupted. I C
In minor bleeding risk surgery and other procedures where bleeding can easily be controlled, it is recommended to perform surgery
without interruption of OAC therapy.
I B
In non-minor bleeding risk procedures in patients using a NOAC, it is recommended to use an interruption regimen based on the
NOAC compound, renal function, and bleeding risk.
I B
In patients using NOACs, it is recommended that minor bleeding risk procedures are performed at trough levels (typically 12–24 h after
last intake).
I C
LMWH is recommended, as an alternative to UFH, for bridging in patients with MHVs and high surgical risk. I B
Bridging of OAC therapy is not recommended in patients with low/moderate thrombotic risk undergoing NCS. III B
Use of reduced-dose NOAC to attenuate the risk of post-operative bleeding is not recommended. III C
Recommendations for peri-operative thromboprophylaxis
It is recommended that decisions about peri-operative thromboprophylaxis in NCS are based on individual and procedure-specific risk
factors.
I A
If thromboprophylaxis is deemed necessary, it is recommended to choose the type and duration of thromboprophylaxis (LMWH,
NOAC, or fondaparinux) according to type of NCS, duration of immobilization, and patient-related factors.
I A
Recommendations for patient blood management in NCS
It is recommended to measure haemoglobin pre-operatively in patients scheduled for intermediate- to high-risk NCS. I B
It is recommended to treat anaemia in advance of NCS in order to reduce the need for RBC transfusion during NCS. I A
In patients undergoing surgery with expected blood loss of ≥500 mL, use of washed cell salvage is recommended. I A
It is recommended to use point-of-care diagnostics for guidance of blood component therapy, when available. I A
Recommendations for management of patients with specific diseases undergoing NCS
A) Patients with CAD
If PCI is indicated before NCS, the use of new-generation DES is recommended over BMS and balloon angioplasty. I A
If NCS can safely be postponed (e.g. at least 3 months), it is recommended that patients with ACS being scheduled for NCS undergo
diagnostic and therapeutic interventions as recommended for ACS patients in general.
I A
Routine myocardial revascularization before low- and intermediate-risk NCS in patients with CCS is not recommended. III B
B) Patients with heart failure
In patients with suspected or known HF scheduled for high-risk NCS, it is recommended to evaluate LV function with echocardiography
and measurement of NT-proBNP/BNP levels, unless this has recently been performed.
I B
It is recommended that patients with HF undergoing NCS receive optimal medical treatment according to current ESC Guidelines. I A
In patients with HF undergoing NCS, it is recommended to regularly assess volume status and signs of organ perfusion. I C
Continued
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A multidisciplinary team including VAD specialists is recommended for peri-operative management of patients with HF receiving
mechanical circulatory support.
I C
C) Patients with VHD
Clinical and echocardiographic evaluation (if not recently performed) is recommended in all patients with known or suspected VHD
who are scheduled for elective intermediate- or high-risk NCS.
I C
AVR (SAVR or TAVI) is recommended in symptomatic patients with severe ASwho are scheduled for elective intermediate- or high-risk
NCS.
I C
In patients with symptomatic severe AR or asymptomatic severe AR and LVESD .50 mm or LVESDi (LVESD/BSA) .25 mm/m2 (in
patients with small body size) or resting LVEF ≤50%, valve surgery is recommended prior to elective intermediate- or high-risk NCS.
I C
In patients with moderate-to-severe rheumatic MS and symptoms or SPAP .50 mmHg, valve intervention (percutaneous mitral
commissurotomy or surgery) is recommended before elective intermediate- or high-risk NCS.
I C
D) Patients with ACHD
In patients with ACHD, a consultation with an ACHD specialist is recommended before intermediate- or high-risk surgery. I C
In patients with ACHD, it is recommended that intermediate- and high-risk elective surgery is performed in a centre with experience in
the care of ACHD patients.
I C
E) Patients with arrhythmias
In patients with SVT controlled by medication, it is recommended that AADs are continued during the peri-operative period. I C
In AF patients with acute or worsening haemodynamic instability undergoing NCS, emergency electrical cardioversion is recommended. I B
In patients with symptomatic, monomorphic, and sustained VT associated with myocardial scar, recurring despite optimal medical
therapy, ablation of arrhythmia is recommended before elective NCS.
I B
It is recommended that patients with temporarily deactivated ICDs have continuous ECG monitoring, and during the peri-operative
period are accompanied by personnel skilled in early detection and treatment of arrhythmias. In high-risk patients (e.g.
pacemaker-dependant or ICD patients), or if access to the torso will be difficult during the procedure, it is recommended to place
transcutaneous pacing/defibrillation pads prior to NCS.
I C
It is recommended that all patients with CIEDs that are reprogrammed before surgery have a re-check and necessary reprogramming as
soon as possible after the procedure.
I C
It is not recommended to initiate treatment of asymptomatic PVC during NCS. III C
F) Patients with pulmonary hypertension
It is recommended to continue chronic therapy for PAH in the peri-operative phase of NCS. I C
It is recommended that haemodynamic monitoring of patients with severe PAH continues for at least 24 h in the post-operative period. I C
In the case of progression of right HF in the post-operative period in patients with PAH, it is recommended that the diuretic dose be
optimized and, if necessary, i.v. prostacyclin analogues be initiated under the guidance of a physician experienced in the management of
PAH.
I C
G) Patients with hypertension
In patients with chronic hypertension undergoing elective NCS, it is recommended to avoid large peri-operative fluctuations in blood
pressure, particularly hypotension, during the peri-operative period.
I A
It is recommended to perform pre-operative screening for hypertension-mediated organ damage and CV risk factors in newly
diagnosed hypertensive patients who are scheduled for elective high-risk NCS.
I C
It is not recommended to defer NCS in patients with stage 1 or 2 hypertension. III C
H) Patients with PAD
In patients with poor functional capacity or with significant risk factors or symptoms (such as moderate-to-severe angina pectoris,
decompensated HF, valvular disease and significant arrhythmia), referral for cardiac work-up and optimization is recommended prior to
elective surgery for PAD or AAA.
I C
Routine referral for cardiac work-up, coronary angiography, or CPET prior to elective surgery for PAD or AAA is not recommended. III C
Continued
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I) Patients with cerebrovascular disease
Pre-operative carotid artery and cerebral imaging is recommended in patients with a history of TIA or stroke in the previous 6 months
and who have not undergone ipsilateral revascularization.
I C
Pre-operative routine carotid artery imaging is not recommended in patients undergoing NCS. III C
J) Patients with renal disease
In patients with known risk factors (age .65 years, BMI .30 kg/m2, diabetes, hypertension, hyperlipidaemia, CV disease, or smoking)
undergoing intermediate- or high-risk NCS, it is recommended to screen for pre-operative renal disease by measuring serum creatinine
and GFR.
I C
K) Patients with obesity
It is recommended to assess cardiorespiratory fitness to estimate peri-operative CV risk in obese patients, with particular attention to
those undergoing intermediate- and high-risk NCS.
I B
L) Patients with diabetes mellitus
A pre-operative assessment for concomitant cardiac conditions is recommended in patients with diabetes with suspected or known
CAD, and those with autonomic neuropathy, retinopathy, or renal disease and scheduled to undergo intermediate- and high-risk NCS.
I C
In patients with diabetes or disturbed glucose metabolism, a pre-operative HbA1c is recommended, if this measurement has been not
performed in the previous 3 months. In case of HbA1c≥8.5% (≥69 mmol/mol), elective NCS should be postponed, if safe and practical.
I B
Recommendations for peri-operative monitoring and anaesthesia
In order to preserve optimal CV stability, it is recommended to apply goal-directed haemodynamic therapy in patients undergoing
high-risk NCS.
I A
It is recommended to avoid post-operative acute pain. I B
In order to minimize the risk of post-operative organ dysfunction, it is recommended to avoid an intra-operative mean arterial pressure
decrease of .20% from baseline values or ,60–70 mmHg for ≥10 min.
I B
Non-aspirin NSAIDs are not recommended as first-line analgesics in patients with established or high risk of CVD. III B
Recommendations for treatment of post-operative cardiovascular complications
It is recommended to have high awareness of peri-operative CV complications, combined with surveillance for PMI in patients
undergoing intermediate- or high-risk NCS.
I B
Systematic PMI work-up is recommended to identify the underlying pathophysiology and define therapy. I B
It is recommended to treat post-operative STEMI, NSTE-ACS, acute HF, and tachyarrhythmias in accordance with guidelines for the
non-surgical setting, after interdisciplinary discussion with the surgeon about bleeding risk.
I C
In patients with post-operative PE of high or intermediate clinical probability, initiation of anticoagulation is recommended without
delay, while diagnostic work-up is in progress, if bleeding risk is low.
I C
Post-operative oral anticoagulation for PE is recommended to be administered for a period of at least 3 months. I C
In patients with a post-operative indication for OAC, NOAC is generally recommended over VKA. I A
Routine use of beta-blocker for the prevention of post-operative AF in patients undergoing NCS is not recommended. III B
©
ES
C
20
22
AAA, abdominal aortic aneurysm; AAD, antiarrhythmic drug; ACHD, adults with congenital heart disease; ACS, acute coronary syndrome; AF, atrial fibrillation; AR, aortic valve
regurgitation; AS, aortic valve stenosis; AVR, aortic valve replacement; BMI, body mass index; BNP, B-type natriuretic peptide; BMS, bare metal stent; BSA, body surface area; CAD,
coronary artery disease; CCS, chronic coronary syndrome; CIED, cardiac implantable electronic device; CPET, cardiopulmonary exercise testing; CV, cardiovascular; CVD,
cardiovascular disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; ECG, electrocardiogram; ESC, European Society of Cardiology; GFR, glomerular filtration rate;
HbA1c, glycated haemoglobin; HF, heart failure; hs-cTn, high-sensitivity cardiac troponin; ICA, invasive coronary angiography; ICD, implantable cardioverter–defibrillator; LMWH,
low molecular weight heparin; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; LVESDi, left ventricular end-systolic
dimension index; MHV, mechanical heart valve; MS, mitral valve stenosis; NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral anticoagulant; NSAID, non-steroidal
anti-inflammatory drug; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; NT-proBNP, N-terminal pro-B-type natriuretic peptide; OAC, oral anticoagulant; PAD,
peripheral artery disease; PAH, pulmonary arterial hypertension; PCI, percutaneous coronary intervention; PE, pulmonary embolism; PMI, peri-operative myocardial infarction/injury;
PVC, premature ventricular contractions; RBC, red blood cell; SAVR, surgical aortic valve replacement; SPAP, systolic pulmonary artery pressure; STEMI, ST-segment elevation
myocardial infarction; SVT, supraventricular tachycardia; TAVI, transcatheter aortic valve implantation; TIA, transient ischaemic attack; TTE, transthoracic echocardiography; UFH,
unfractionated heparin; VAD, ventricular assist device; VHD, valvular heart disease; VKA, vitamin K antagonist; VT, ventricular tachycardia.
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13. Quality indicators
Quality indicators (QIs) are tools that may be used to evaluate care
quality, including structural, process, and outcomes of care.698 They
may also serve as a mechanism for enhancing adherence to guideline
recommendations, through associated quality improvement initia-
tives and the benchmarking of care providers.699,700 As such, the
role of QIs in improving care and outcomes for CV disease is increas-
ingly being recognized by healthcare authorities, professional organi-
zations, payers, and the public.698
The ESC understands the need for measuring and reporting quality
and outcomes of CV care and has established methods for the devel-
opment of the ESCQIs for the quantification of care and outcomes for
CV diseases.698 To date, the ESC has developedQI suites for a number
of CV diseases701–703 and embedded these in respective ESC Clinical
Practice Guidelines (2020 ESC Guidelines for the diagnosis and man-
agement of atrial fibrillation; 2021 ESC Guidelines for the diagnosis
and treatment of acute and chronic heart failure; and 2021 ESC
Guidelines on cardiac pacing and cardiac resynchronization ther-
apy).99,412,481,704 Furthermore, the ESC aims to integrate its QIs with
clinical registries such as the EURObservational Research Programme
(EORP) and the European Unified Registries On Heart Care
Evaluation and Randomized Trials (EuroHeart) project705 to provide
‘real-world’ data about the patterns and outcomes of care for CV dis-
ease across Europe.
In parallel with the writing of this Clinical Practice Guideline docu-
ment, a process has been initiated to develop QIs for patients under-
going NCS using the ESC methodology and through collaboration
with patient representatives and domain experts. Such QIs may be
used for evaluation of the quality of care for this group of patients
and enable capture of important aspects of care delivery. The QIs,
alongside their measurement specifications and development pro-
cess, will be published in a separate paper.
14. Central illustration
There is a complex interplay between the intrinsic risk of surgery and
the patient-related risk of peri-operative CV complications. This lat-
ter risk depends on the baseline general and CV status of patients
scheduled for NCS. For each patient, the proper quantification and
communication of the surgical risk require close cooperation be-
tween cardiologists, surgeons, anaesthesiologists, general practi-
tioners, and other healthcare providers (Figure 21).
Comorbidity risk
Hypoxic/hypotensive/
hypovolaemic risk
Thrombotic/bleeding risk
Haemodynamic/
arrhythmic risk
Surgical
risk
High
Intermediate
Low
Ageing/metabolic and autonomic
dysregulation/hypertension/
chronic kidney disease
Central/systemic
gas-exchange balance
Diastolic/systolic
dysfunction and
pulmonary congestion
Rhythm diso
device ther
Valvular heart disease
Withdrawal/continuation
antithrombotic drugs
Acute/chronic
coronary syndrome
Fluid/blood loss O2 CO2
Figure 21 Central illustration: the complex interplay between the intrinsic risk of surgery and the patient risk of peri-operative cardiovascular
complications.
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15. Supplementary data
Supplementary data is available at European Heart Journal online.
16. Data availability statement
No new data were generated or analysed in support of this research.
17. Author information
Author/Task Force Member Affiliations: Salvatore
Cassese, Klinik für Herz- und Kreislauferkrankungen, Deutsches
Herzzentrum München, Munich, Germany; Trygve S. Hall,
Department of Cardiology, Oslo University Hospital, Ullevål, Oslo,
Norway; Magdy Abdelhamid, Cardiology Department, Faculty
of Medicine, Kase Al Ainy, Cairo University, Cairo, Egypt;
Emanuele Barbato, Advanced Biomedical Sciences, University
Federico II, Naples, Italy, Cardiovascular Center Aalst, OLV
Hospital, Aalst, Belgium; Stefan De Hert, Department of
Anesthesiology and Perioperative Medicine, Ghent University
Hospital/Ghent University, Ghent, Belgium; Tobias Geisler,
Department of Cardiology and Angiology, University Hospital
Tübingen, Tübingen, Germany; Lynne Hinterbuchner,
Department of Cardiology, Clinic of Internal Medicine II,
Paracelsus Medical University of Salzburg, Salzburg, Austria; Borja
Ibanez, Clinical Research Department, Centro Nacional de
Investigaciones Cardiovasculares (CNIC), Madrid, Spain,
Cardiology Department, Fundación Jiménez Díaz Hospital, Madrid,
Spain, CIBERCV Centro Investigacion Biomedica en Red, Madrid,
Spain; Ingrid de Laval (Sweden), ESC Patient Forum, Sophia
Antipolis, France; Radosław Lenarczyk, Department of
Cardiology, Congenital Heart Diseases and Electrotherapy, The
Medical University of Silesia, Division of Medical Sciences in
Zabrze, Zabrze, Poland, Silesian Center for Heart Disease, Zabrze,
Poland; Ulrich R. Mansmann, Institute for Medical Data
Processing, Biometry, and Epidemiology, Ludwig-Maximilian’s
University, Munich, Germany; Paul McGreavy (United Kingdom),
ESC Patient Forum, Sophia Antipolis, France; Christian Mueller,
Cardiovascular Research Institute Basel, University Heart Center,
University Hospital Basel, Basel, Switzerland, University of Basel,
Basel, Switzerland; Claudio Muneretto, Cardiothoracic,
University of Brescia Italy, Brescia, Italy; Alexander Niessner,
Department of Internal Medicine II, Division of Cardiology, Medical
University of Vienna, Vienna, Austria; Tatjana S. Potpara,
School of Medicine, Belgrade University, Belgrade, Serbia,
Cardiology Clinic, University Clinical Center of Serbia, Belgrade,
Serbia; Arsen D. Ristić, Faculty of Medicine, Belgrade University,
Belgrade, Serbia, Department of Cardiology, University Clinical
Center of Serbia, Belgrade, Serbia; L. Elif Sade, Heart and
Vascular Institute, University of Pittsburgh Medical Center,
Pittsburgh, PA, United States of America, Cardiology, University of
Baskent, Ankara, Turkey; Henrik Schirmer, Department of
Cardiology, Akershus University Hospital, Lørenskog, Norway,
Institute of Clinical Medicine, Campus Ahus, University of Oslo,
Lørenskog, Norway; Stefanie Schüpke, ISAResearch Center,
Deutsches Herzzentrum München, Munich, Germany, Heart
Alliance, DZHK (German Center for Cardiovascular Research),
Munich, Germany; Henrik Sillesen, Vascular Surgery,
Rigshospitalet, University of Copenhagen, Copenhagen, Denmark,
Clinical Medicine, University of Copenhagen, Copenhagen,
Denmark; Helge Skulstad, Department of Cardiology, Clinic of
heart-, lung- and vessel disease, Oslo University Hospital, Oslo,
Norway, Institute of Clinical Medicine, University of Oslo, Oslo,
Norway; Lucia Torracca, Cardiac Surgery, IRCCS Humanitas
Research Hospital, Milano, Italy; Oktay Tutarel, Department of
Congenital Heart Disease and Paediatric Cardiology, German
Heart Centre Munich, TUM School of Medicine, Technical
University of Munich, Munich, Germany, DZHK (German Centre
for Cardiovascular Research), partner site Munich Heart Alliance,
Munich, Germany; Peter Van der Meer, Cardiology, University
Medical Center Groningen, Groningen, Netherlands; Wojtek
Wojakowski, Division of Cardiology and Structural Heart
Diseases, Medical University of Silesia, Katowice, Poland; and Kai
Zacharowski, Anaesthesiology, Intensive Care Medicine & Pain
Therapy, University Hospital Frankfurt, Goethe University,
Frankfurt, Germany.
18. Appendix
ESC Scientific Document Group: includes Document
Reviewers and ESC National Cardiac Societies.
Document Reviewers: Juhani Knuuti (CPG Review
Coordinator) (Finland), Steen Dalby Kristensen (CPG Review
Coordinator) (Denmark), Victor Aboyans (France), Ingo Ahrens
(Germany), Sotiris Antoniou (United Kingdom), Riccardo
Asteggiano (Italy), Dan Atar (Norway), Andreas Baumbach (United
Kingdom), Helmut Baumgartner (Germany), Michael Böhm
(Germany), Michael A. Borger (Germany), Hector Bueno (Spain),
Jelena Čelutkienė (Lithuania), Alaide Chieffo (Italy), Maya Cikes
(Croatia), Harald Darius (Germany), Victoria Delgado (Spain),
Philip J. Devereaux (Canada), David Duncker (Germany), Volkmar
Falk (Germany), Laurent Fauchier (France), Gilbert Habib (France),
David Hasdai (Israel), Kurt Huber (Austria), Bernard Iung (France),
Tiny Jaarsma (Sweden), Aleksandra Konradi (Russian Federation),
Konstantinos C. Koskinas (Switzerland), Dipak Kotecha (United
Kingdom), Ulf Landmesser (Germany), Basil S. Lewis (Israel), Ales
Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Michael
Maeng (Denmark), Stéphane Manzo-Silberman (France), Richard
Mindham (United Kingdom), Lis Neubeck (United Kingdom), Jens
Cosedis Nielsen (Denmark), Steffen E. Petersen (United Kingdom),
Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Antti
Saraste (Finland), Dirk Sibbing (Germany), Jolanta M. Siller-Matula
(Austria), Marta Sitges (Spain), Ivan Stankovic (Serbia), Rob
F. Storey (United Kingdom), Jurrien ten Berg (Netherlands),
Matthias Thielmann (Germany), and Rhian M. Touyz (Canada/
United Kingdom).
ESC National Cardiac Societies actively involved in the re-
view process of the 2022 ESC Guidelines on assessment and man-
agement of patients undergoing non-cardiac surgery
Algeria: Algerian Society of Cardiology, Mohammed Amine
Bouzid; Armenia: Armenian Cardiologists Association, Hamayak
Sisakian; Austria: Austrian Society of Cardiology, Bernhard
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Metzler; Belarus: Belorussian Scientific Society of Cardiologists,
Vadim Shumavets; Belgium: Belgian Society of Cardiology, Agnès
Pasquet; Bosnia and Herzegovina: Association of Cardiologists
of Bosnia and Herzegovina, Elnur Smajic; Bulgaria: Bulgarian
Society of Cardiology, Maria Milanova; Croatia: Croatian Cardiac
Society, Boško Skorić; Cyprus: Cyprus Society of Cardiology,
Maria Karakyriou; Czechia: Czech Society of Cardiology, Hana
Skalicka; Denmark: Danish Society of Cardiology, Michael Maeng;
Egypt: Egyptian Society of Cardiology, Bassem Abd Elhamid;
Estonia: Estonian Society of Cardiology, Arno Ruusalepp;
Finland: Finnish Cardiac Society, Kati Valtola; France: French
Society of Cardiology, Ariel Cohen; Georgia: Georgian Society of
Cardiology, Archil Chukhrukidze; Germany: German Cardiac
Society, Ilka Ott; Greece: Hellenic Society of Cardiology, Nikos
Kafkas; Hungary: Hungarian Society of Cardiology, Zoltán Járai;
Iceland: Icelandic Society of Cardiology, Thórdís Jóna
Hrafnkelsdóttir; Ireland: Irish Cardiac Society, Patricia Campbell;
Israel: Israel Heart Society, Alon Eisen; Italy: Italian Federation of
Cardiology, Stefano Urbinati; Kazakhstan: Association of
Cardiologists of Kazakhstan, Nazipa Aidargaliyeva; Kosovo
(Republic of): Kosovo Society of Cardiology, Arlind Batalli;
Kyrgyzstan: Kyrgyz Society of Cardiology, Olga Lunegova;
Latvia: Latvian Society of Cardiology, Andrejs Erglis; Lebanon:
Lebanese Society of Cardiology, Georges Saade; Lithuania:
Lithuanian Society of Cardiology, Andrius Macas; Luxembourg:
Luxembourg Society of Cardiology, Cristiana Banu; Malta: Maltese
Cardiac Society, Tiziana Felice; Moldova: Moldavian Society
of Cardiology, Aurel Grosu; Montenegro: Montenegro Society
of Cardiology, Mihailo Vukmirovic; Morocco: Moroccan
Society of Cardiology, Aida Soufiani; Netherlands: Netherlands
Society of Cardiology, Eric Dubois; North Macedonia: North
Macedonian Society of Cardiology, Hristo Pejkov; Norway:
Norwegian Society of Cardiology, Erlend Aune; Poland: Polish
Cardiac Society, Stanisław Bartuś; Portugal: Portuguese Society
of Cardiology, Mário Santos; Romania: Romanian Society of
Cardiology, Elisabeta Badila; Russian Federation: Russian
Society of Cardiology, Olga Irtyuga; San Marino: San Marino
Society of Cardiology, Luca Bertelli; Serbia: Cardiology Society of
Serbia, Branko Beleslin; Slovakia: Slovak Society of Cardiology,
Martin Dúbrava; Slovenia: Slovenian Society of Cardiology, Zlatko
Fras; Spain: Spanish Society of Cardiology, José Luis Ferreiro;
Sweden: Swedish Society of Cardiology, Claes Held;
Switzerland: Swiss Society of Cardiology, Philippe Meyer;
Syrian Arab Republic: Syrian Cardiovascular Association, Walid
Bsata; Tunisia: Tunisian Society of Cardiology and
Cardio-Vascular Surgery, Afef Ben Halima; Turkey: Turkish
Society of Cardiology, Murat Biteker, United Kingdom of
Great Britain and Northern Ireland: British Cardiovascular
Society, Andrew Archbold; Ukraine: Ukrainian Association of
Cardiology, Maksym Sokolov; and Uzbekistan: Association of
Cardiologists of Uzbekistan, Nodir Zakirov.
ESC Clinical Practice Guidelines (CPG) Committee:
Colin Baigent (Chairperson) (United Kingdom), Magdy Abdelhamid
(Egypt), Victor Aboyans (France), Sotiris Antoniou (United
Kingdom), Elena Arbelo (Spain), Riccardo Asteggiano (Italy),
Andreas Baumbach (United Kingdom), Michael A. Borger
(Germany), Jelena Čelutkienė (Lithuania), Maja Cikes (Croatia),
Jean-Philippe Collet (France), Volkmar Falk (Germany), Laurent
Fauchier (France), Chris P. Gale (United Kingdom), Sigrun
Halvorsen (Norway), Bernard Iung (France), Tiny Jaarsma
(Sweden), Aleksandra Konradi (Russian Federation), Konstantinos
C. Koskinas (Switzerland), Dipak Kotecha (United Kingdom), Ulf
Landmesser (Germany), Basil S. Lewis (Israel), Ales Linhart (Czech
Republic), Maja-Lisa Løchen (Norway), Richard Mindham (United
Kingdom), Jens Cosedis Nielsen (Denmark), Steffen E. Petersen
(United Kingdom), Eva Prescott (Denmark), Amina Rakisheva
(Kazakhstan), Marta Sitges (Spain), and Rhian M. Touyz (Canada
/United Kingdom).
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