Implementation of 2022 ESC guidelines for cardiovascular assessment before non-cardiac surgery

Major concerns to meet in the near future!

We read with a great interest the recent updated version of the ESC guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery.¹ Significant changes have been made when compared with the previous recommendations published in 2014, and some of those new recommendations clearly ask questions of anaesthesiologists regarding both feasibility and clinical ramifications. Moreover, those new recommendations were endorsed in-extenso by the ESAIC. Consequently, we wondered how far current practice in our teaching university hospital now deviates from them, and how long it might take to implement them on a daily basis across the whole anaesthesiology team. Especially noteworthy, inter alia, were the pivotal recommendations on the use of preoperative resting transthoracic echocardiography (TTE), and assays of pre and postoperative cardiac biomarkers. These have been markedly reinforced in the 2022 version¹ and have the potential for huge modifications of healthcare providers’ practice and a major impact on hospital service organisation.

In consequence, we performed a 1-day retrospective, single-centre cohort study, including all adult patients scheduled for a non-cardiac surgical procedure that required the presence of at least one member of the anaesthesiology team. Obstetric and cardiological procedures were not included. The main goal of the study was to examine the ratio of actually performed tests versus those recommended regarding both preoperative TTE and NT-proBNP/BNP assays. Two hundred and fifty adult patients met the inclusion criteria. Among them, 72% (179/250) had cardiovascular risk factors, including age at least 65 years, and 34% (85/250) had known cardiovascular disease. Surgical procedures were elective (50%), time-sensitive (31%) or urgent/immediate (19%), and classified as high-risk (2%), intermediate-risk (22%), low-risk (24%) or unclassified (52%). According to the new guidelines, preoperative resting TTE was recommended for 17% (43/250) of these patients, predominantly with a IIb class recommendation (41/43). The performed : recommended ratio on preoperative TTE was 0.21 (9/43). Preoperative NT-pro-BNP/BNP assays were recommended in 24% (61/250) of patients, with a I class recommendation for 26 patients and a IIa class recommendation for 35 patients. The performed : recommended ratio on preoperative NT-proBNP/BNP was 0 (0/61).

These results clearly show the dramatic gap between the most recent guidelines and routine practice in our tertiary centre. There are three major concerns which will result from guideline implementation in the near future. First, it seems obvious that the surgical risk estimate according to the type of surgery or intervention has only been slightly modified compared with the previous classification,² and the method proposed to discriminate between high-risk and intermediate-to-low risk is not appropriate. Indeed, more than 50% of our surgical procedures were unclassified by the clinicians, mainly because numerous operative procedures are not listed. Thus, upper limb orthopaedic surgery, colectomy or digestive endoscopy could not be easily classified by practitioners as they do not specifically appear in the published table. Moreover, high surgical risk is variably estimated across the quality indicators in the same guidelines, adding to the confusion with this classification.³

Second, preoperative resting TTE has gained an increasing role despite lack of evidence that it reduces postoperative major adverse cardiovascular events and mortality.^4,5 Nevertheless this leads to a significant proportion of patients in our cohort that ‘should’ have undergone TTE according to the guidelines. This proportion of patients would represent nearly one-third of the daily total TTE throughput in our echocardiography lab. Moreover, the number of ‘required’ preoperative TTE was probably underestimated since more than half of the surgical procedures were unclassified. Significantly, the role of resting TTE was somewhat limited in the Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo non-cardiac surgery, published only a couple of years ago.⁶ Anyway, both a re-organisation of the echo lab and focused cardiac ultrasound exams performed by trained specialists other than cardiologists would be necessary both to meet the new ESC guidelines (class IIb, level B)¹ and to avoid delaying surgery.

Third, with the significantly upgraded recommendations in the 2022 version regarding cardiac biomarkers, while in accordance with the Canadian guidelines,⁶ the liberal use of perioperative biomarkers, strongly demands a thorough explanation of what the proposed virtuous circle of this use of perioperative cardiac biomarkers is. Indeed, the worldwide cost of such a liberal use of biomarkers should be counterbalanced by a credible medical decision for a given patient (to do or not to do), and by a sustained clinical benefit in routine practice.⁷ Some differences in the methodological approach, also taking into account practical and clinical aspects of perioperative cardiac risk assessment, could lead to potentially different recommendations in the upcoming focused guidelines of the ESAIC on perioperative use of cardiac biomarkers.