This Invited Commentary accompanies the following article:
Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 2014; 31:517–573.
It has become usual for different specialties to write multi-disciplinary guidelines when ‘teams’ of physicians collaborate daily in patient care. This is typically the case for cardiovascular assessment and management of patients who undergo non-cardiac surgery.1
The goals of this Invited Commentary are to briefly summarise the main domains of the cardiology part of the guidelines that are of primary relevance for anaesthesiologists (e.g. peri-operative use of β-blockers, biomarkers, the electrocardiogram, rest echocardiography) and to discuss a few recommendations that may change the practice of anaesthesia and peri-operative care.
Why was the update of these European Society of Cardiology/European Society of Anaesthesiology guidelines necessary?
The answer is because the number of patients with cardiovascular diseases who undergo surgery and have peri-operative complications is high. The magnitude of the problem is difficult to measure in detail but can be approached in terms of the size of the adult non-cardiac surgical group and the average risk of cardiac complications in this cohort. For Europe, with an overall population of over 500 million, there are approximately 19 million major surgical procedures per year, of which approximately 30% are performed in the presence of cardiovascular co-morbidity (approximately 5.7 million procedures/year). The average overall annual complication rate is between 7 and 11%, and the mortality rate is 0.8 to 1.5%; up to 42% of these are caused by cardiac complications. For the European Union member states, these figures represent 167 000 cardiac complications, of which 19 000 are life-threatening. It is estimated that the number of patients undergoing surgery will increase by 25% by the year 2020. In the same time period, the elderly population will increase by 50%. Therefore, the magnitude of the problem clearly accounts for the necessity for (updated) guidelines.
Another issue that explains the updated guidelines is the role of peri-operative β-blockade in the prevention of cardiac complications after non-cardiac surgery. Previous guidelines put emphasis on, and a central role for, peri-operative β-blockade, even recommending de-novo initiation before the surgery in certain classes of patients.2,3 This strategic approach has been challenged by the results of the Peri-Operative ISchemic Evaluation-1 trial, which observed that a beneficial effect of peri-operative blockade on the incidence of peri-operative myocardial infarction was at the expense of increased mortality related to the occurrence of peri-operative stroke (probably secondary to peri-operative arterial hypotension).4 In addition, it became evident that specifically the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo (DECREASE) studies – which contributed in large part as scientific background for the previous recommendation on peri-operative β-blocking therapy – should be discredited for various reasons.5 These different issues prompted the editorial office of the European Heart Journal to publish an expression of concern6 and the commitment to address this issue in the new guidelines.
The novelties of the 2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines are as follows.
- The role of the anaesthesiologist: Anaesthesiologists (a term that refers to those physicians trained in anaesthesia and intensive care) have a leading role in identifying patients who require pre-operative evaluation by a team of integrated multi-disciplinary specialists including anaesthesiologists, cardiologists and surgeons, and when appropriate an extended team (e.g. internists, pulmonologists or geriatricians). Selected patients include those identified by the anaesthesiologist due to the following: suspected or known cardiac disease with sufficient complexity to carry a potential peri-operative risk (e.g. congenital heart disease, unstable symptoms or low functional capacity); patients in whom pre-operative medical optimisation is expected to reduce peri-operative risk before low-risk and intermediate-risk surgery; and patients with known or high risk of cardiac disease undergoing high-risk surgery.
- Evaluation of surgical risk: The evaluation of surgical risk has not changed profoundly from the 2009 recommendations. It is still based on low (<1%), intermediate (1 to <5%) and high risk (≥5%). Nevertheless, the wide variety of surgical procedures with different contexts makes it difficult to assign a specific risk of a major adverse cardiac event to each procedure. When invasive/less invasive procedures are available for the same pathologies and there is alteration of cardiovascular reserve, it has been recommended that less invasive procedures be considered by the multi-disciplinary team. This is based on the assumption that major complications are less frequent after less invasive procedures.
- Pre-operative risk scores for non-cardiac surgery patients: There was much debate within the ESC/ESA Task Force on the relative merits of pre-operative risk scores. It was concluded that although the Revised Cardiac Risk Index (RCRI or Lee score) is not the strongest in terms of discrimination, the alternatives (e.g. NSQIP from the American College of Surgeons National Surgical Quality Improvement Program database) required calculations (available on (http://www.surgicalriskcalculator.com/miorcardiacarrest). The consensus opinion was that the two scores provide complementary prognostic perspectives and can help the clinician in the decision-making process. The advantage of RCRI is its facility of use and this is why the ESA members of the Task force insisted on keeping the RCRI despite its lower discriminative performance.
- Peri-operative measurement of cardiac biomarkers in selected patients: Previous ESC/ESA or American Heart Association/American College of Cardiology guidelines did not recommend the use of pre-operative and post-operative biomarkers, but the 2014 ESC/ESA guidelines stipulate that the assessment of cardiac troponins in high-risk patients, both before and 48 to 72 h after major surgery, may be considered (Class of recommendation IIb/Level of evidence B). Similarly, N-terminal pro-brain natriuretic peptide (NT-proBNP) or BNP measurements may be considered for obtaining independent prognostic information for peri-operative and late cardiac events in high-risk patients (IIb/B). It must be underlined that routine pre-operative biomarker sampling in all patients for risk stratification and to prevent cardiac events is not recommended (III/C). The impact of these recommendations on peri-operative management of patients who must undergo non-cardiac surgery is still to be determined, but these recommendations clearly set up the beginning of use of biomarkers as part of peri-operative management.
- ECG and echocardiography: For the two most prescribed tests by anaesthesiologists, that is ECG and echocardiography, the guidelines stipulate that pre-operative ECG is recommended for patients with risk factors (according to the pre-operative risk scores) if they must undergo intermediate-risk or high-risk surgery (I/C), pre-operative ECG may be considered (IIb/C) for patients with risk factors and low-risk surgery or for patients with no risk factors but who are older than 65 years and must undergo intermediate-risk surgery, and rest echocardiography may be considered as part of pre-operative evaluation in patients undergoing high-risk surgery (IIb/C).
- Pharmacological risk reduction strategies: This was probably the most difficult part of the guideline-writing process because of the controversy on the peri-operative use of β-blockers, and the recent data on peri-operative use of aspirin and clonidine. To summarise this section on β-blockers, the strategies are as follows: peri-operative continuation of β-blockers is recommended in patients currently treated with β-blockers (I/B); pre-operative initiation of β-blockers may be considered (IIb/B) (preferably with atenolol or bisoprolol as a first choice; IIb/B) in patients scheduled for high-risk surgery and who have at least two clinical risk factors or American Society of Anesthesiologists’ (ASA) physical status at least 3, or in patients who have known ischaemic heart disease or myocardial ischaemia; β-blockers should not be initiated pre-operatively (III/B) at high doses without titration or in patients who must undergo low-risk surgery.
- Peri-operative continuation of statins is recommended, favouring statins with a long half-life or extended-release formulation (I/C). Pre-operative initiation of statins may be considered (starting at least 2 weeks before) for patients who undergo vascular surgery (IIa/B).
- Novelties concerning aspirin, dual anti-platelet therapy and the direct oral anti-coagulants are too numerous to be discussed in this statement, but there are many changes in the 2014 ESC/ESA guidelines. The complexity of these therapies, independent from the peri-operative period, are such that their peri-operative management will be a major task of the ‘peri-operative team’.
- Intra-operative and post-operative anaesthetic management: Some recommendations regarding intra-operative and post-operative anaesthetic management have changed since the previous guidelines.
- The first change is related to the fact that recent articles found statistical associations between intra-operative arterial hypotension (defined as decreases >20% of mean arterial pressure, or mean arterial pressure values <60 mmHg for cumulative durations of >30 min) and an increased risk of post-operative complications (myocardial infarction, stroke and death). Therefore, avoidance of arterial hypotension (a process more complex than mere correction of arterial pressure values through infusion of vasoconstrictors) has been recommended (IIb/B). The IIb classification was selected because the relationship between arterial hypotension and post-operative cardiovascular complications/death was obtained in observational studies only. The term ‘avoidance’ (rather than ‘correction’) is a tribute to methodological constraints related to the guideline-writing process. Avoidance covers different approaches from anticipation/diagnosis/correction of hypovolaemia to diagnosis and correction of anaesthetic drug overdose (detected most easily through cortical electroencephalography (EEG) or EEG-based depth of anaesthesia monitors). From the recent literature, it is impossible to assert that correction of intra-operative arterial hypotension through the use of different vasconstrictors will affect the direction of the relationship between intra-operative arterial hypotension and post-operative outcome. It will become obvious for all those who read attentively the 2014 ESC/ESA guidelines that the task force did not recommend the use of EEG-based depth of anaesthesia monitors in patients with altered cardiovascular reserve because it was considered that the studies relating anaesthetic drug overdose to worse post-operative outcome were subject to many methodological difficulties. Despite this, the ESA members of the task force consider that diagnosis/correction of anaesthetic drug overdose is part of the process of ‘avoidance’ of intra-operative arterial hypotension.
- The fact that intra-operative haemodynamic instability is associated with post-operative complications allows for risk stratification at the end of surgery. This has been the result of the use of the surgical Apgar score.7 It is therefore possible to stratify the risk based not only on pre-operative factors but also on intra-operative events. The benefit of immediate post-operative risk stratification could be related to better identification of patients who may require special attention in the post-operative period (e.g. measurement of cardiac-specific troponin or natriuretic peptides, or continued observation in the ICU).
- A second major issue regarding peri-operative management concerns the recommendation on haemodynamic optimisation. Patients with high cardiac and surgical risk should be considered for goal-directed therapy (IIa/B). This recommendation is based on several meta-analyses. The implications of this recommendation for the organisation of the anaesthesia/peri-operative care processes are difficult to assess for the moment, but it seems clear that putting this recommendation into practice will require identification of specific subgroups of patients and definition of processes of care (what monitors, what interventions, location of the patients, etc.).
- The third major change concerns the fact that neuraxial anaesthesia alone (but not when associated with general anaesthesia) has been shown to decrease the risk of major post-operative complications. Neuraxial anaesthesia (alone) can therefore be considered as the anaesthetic technique of choice following careful assessment of the risk/benefit ratio for each patient. Similarly, neuraxial analgesia is also associated with better post-operative outcome and should therefore be considered as the technique of first choice (following careful assessment of individual risk/benefit profile).
In conclusion, it is obvious that the role conferred on anaesthesiologists both as members of the ‘cardiac peri-operative team’, as initiators of the patient selection process and as contributors (through management of anaesthesia and the post-operative period) has changed since the 2009 ESC/ESA guidelines in which the intra-operative period was ‘invisible’ in terms of outcome. This will increase the workload and the responsibility of anaesthesia teams. The next steps are, of course, careful reading and analysis of the 2014 ESC/ESA guidelines followed by implementation in all institutions.
Acknowledgements relating to this article
Assistance with the commentary: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Comment from the Editor: this Invited Commentary was checked and accepted by the editors but was not sent for external peer review. DL, AH and SDH are co-authors of the 2014 ESC/ESA Guidelines on non-cardiac surgery. SDH is an associate editor of the European Journal of Anaesthesiology.
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