Recently, the ESC 2022 Guidelines for Cardiovascular Assessment and Management of Non-cardiac Surgery Patients were promulgated. Based on the latest clinical research results, the guidelines have been improved on the basis of the previous version, and new chapters and recommendations have been added. Professor Sigrun Halvorsen from Oslo University Hospital, Norway, was invited to interpret the Guidelines based on her clinical experience.
International Circulation: At this Conference, the ESC 2022 Guideline on Cardiovascular Assessment and Management of Patients Undergoing Non-Cardiac Surgery was published. Could you please introduce the highlights of this Guideline?
Professor Sigrun Halvorsen: The most important changes in this new Guideline are probably related to our introduction of a Class I recommendation to measure biomarkers before surgery as risk-prediction markers, and also to repeat the cardiac components 24 and 48 hours after surgery in order to detect what we call perioperative myocardial infarctions. That is an update from previous practice as it has been shown to be very important, because elevated biomarkers before surgery tell us these patients are at increased risk for complications, therefore, it is most important to do what we can to reduce the risk before surgery and that we monitor these patients more closely during and after surgery. If troponins get elevated after surgery, in accordance with the definition of a myocardial infarction, it is important that we try to find out the cause, because this is a heterogeneous group of patients. In some patients, it can be due to myocardial ischemia; and in others patients, due to hypertension or arrhythmia. So it is very important that we try to find out what the cause is and treat the cause, in order to reduce the risk of serious complications and death.
International Circulation: Could share with us the incidence of cardiac complications in non-cardiac surgery patients around the world?
Professor Sigrun Halvorsen: The incidence is high, depending on the type of surgery. The incidence is higher if it is higher risk surgery compared to intermediate or lower risk surgery. So it is very difficult to come up with a figure, but we do know that more than 4 million people die post-operatively every year from surgery. That makes post-operative death the third most important cause of death worldwide. We really need to improve our care of these patients in order to reduce the number of these post-operative deaths. I think we haven’t been good enough, but now we have some new tools, particularly with these biomarkers, in order to identify those patients with highest risk. The next step is to implement this in practice and also try to reduce risk in these patients as much as we can.
International Circulation: How do we do perioperative cardiovascular monitoring and management of non-cardiac surgery patients?
Professor Sigrun Halvorsen: We have constructed many flowcharts and figures on how to manage these patients, but for the initial assessment of all patients, we recommend taking an accurate history and doing a full clinical examination, including standard blood tests, such as hemoglobin and creatinine. Then, in patients with an elevated risk such as those with previously known cardiovascular disease, and in all patients above the age of 65 (because we know that age is an important risk factor for post-operative complications), we recommend measuring for troponins or BNP or both of those, in addition to doing an ECG. That is the first stage of stratification. If we detect patients with elevated troponin and BNPs, we have to try to find out what kind of disease is causing that and to treat that disease (heart failure, ACS, etc.) optimally before the patient undergoes surgery. Also, as I have said already, we have a very strong focus on biomarkers in the new Guideline, so it is not just before surgery, it is also in the post-operative phase that we need to monitor troponins in addition to the more usual parameters such as blood pressure, pulse and ECGs.
International Circulation: What are the clinical strategies for reducing perioperative risk in patients undergoing non-cardiac surgery?
Professor Sigrun Halvorsen: That is a very good question. There have been quite a few studies performed to try to find risk reduction strategies. For instance, there have been studies with initiation of specific drugs a day or two before surgery, such as beta-blockers, aspirin, and clonidine to name a few, but none of these have been shown to be particularly beneficial. So we cannot recommend starting any specific drug therapy in order to reduce risk, but we do know that the risk is smaller if the patient is in a stable phase. If you have heart failure or hypertension or ACS, the situation should be stabilized and the patient treated according to the guidelines for heart failure, hypertension or ACS to ensure that the patient is optimally treated before surgery. Then the risk of complications will be lower. What we have also found out recently is that if the patient is smoking, it is very useful to stop smoking. Stopping smoking will reduce the risk of complications significantly, also the risk of death. You need to stop smoking at least four weeks before surgery, so this needs to be planned and the surgery postponed if the patient does smoke prior to presenting for surgery, because that will reduce the risk of complications. It is really important.
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