1 de Hert

2014 ESC / ESA guidelines on
non-cardiac surgery:
cardiovascular assessment and management
Stefan De Hert, MD, PhD

Department of Anesthesiology
Ghent University Hospital
Ghent University
Belgium
© 2010 Universitair Ziekenhuis Gent
disclosures ?
© 2010 Universitair Ziekenhuis Gent 2

disclosures ?
member, ESA Guidelines Committee
member, 2009 ESC/ESA Task Force for Preoperative Cardiac Risk

Assessment and Perioperative Cardiac Management in Non-cardiac
surgery
Eur Heart J 2009; 30: 2769 – 2812
Eur J Anaesthesiol 2010; 27: 92 – 137
chair, ESA Task Force on Preoperative evaluation of the adult patient

undergoing non-cardiac surgery
Eur J Anaesthesiol 2011; 28: 684 – 722
member, 2014 ESC/ESA joint task Force on Non-cardiac surgery:

cardiovascular assessment and management
Eur Heart J 2014; 35: 2383 – 2431
Eur J Anaesthesiol 2014 ; 31: 517 – 573
chair, ESA Task Force for the revision of the 2011 guidelines on
preoperative evaluation of the adult patient undergoing non-cardiac
surgery
why new guidelines ?

what is new ?

what is new ?
è role of the anesthesiologists
è evaluation of surgical risk
è pre-operative risk scores
è ECG and echocardiography
è pharmacological risk reduction strategies
è intra- and postoperative anesthetic management

role of the anesthesiologists (society)

role of the anesthesiologists (society)

evaluation of surgical risk

ACC / AHA guidelines
emergent è intervention within 6 hrs

urgent è delay: 6 and 24 hrs
time sensitive è delay: >1 to 6 weeks
elective è delay up to 1yr
LOW risk è risk of MACE < 1%

HIGH risk è risk of MACE ≥ 1%

ESC / ESA guidelines

variety of surgical procedures
in different clinical contexts
è difficult to assign a specific risk

to a specific procedure
è invasive / less invasive procedure ?
è assumption: less invasive = less risk

pre-operative risk scores

Revised Cardiac Risk Index (RCRI or Lee score)
http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/
24 studies including > 790,000 pts
moderately good discrimination of high vs low risk for cardiac

events
è for MIXED non-cardiac surgery
è NOT for VASCULAR non-cardiac surgery
è NOT for predicting mortality
AUC for predicting perioperative cardiac events
and all-cause mortality

Revised Cardiac Risk Index risk for MACE
1. high risk surgery
(suprainguinal vascular, intraperitoneal, or 0 predictors = 0.4%,
intrathoracic )
2. history of ischemic heart disease
1 predictor = 0.9%,
2 predictors = 6.6%,
3. history of congestive heart failure
≥ 3 predictors = >11%
4. history of cerebrovascular disease
(stroke or transient ischemic attack)
5. history of diabetes requiring insulin

use
6. chronic kidney disease

(creatinine > 1.5 - 2 mg/dL)
National Surgical Quality Improvement (NSQIP)
http://www.surgicalriskcalculator.com/miorcardiacarrest
American College of Surgeons multicenter

prospective database including 211,410 pts
NSQIP
1. type of surgery
2. dependent functional status
3. abnormal creatinine
4. ASA class
5. increasing age

http://riskcalculator.facs.org/

è BETTER predictive performance than RCRI
BUT less user-friendly (need for calculation program)
scores provide complementary information

perioperative monitoring
electrocardiography

pharmacological risk reduction strategies

others ?
2009

others ?
2009

intra- and postoperative anesthetic
management

intra- and postoperative anesthetic
management
è intra-operative hypotension
è hemodynamic optimization
è intra-operative risk stratification
è anesthetic technique / agent
è identification of patient at risk and

intensification of therapy
intra-operative hypotension

association ≠ causal relationship
è NO evidence that
treatment of hypotension
improves outcome
è hypotension should be
AVOIDED
hemodynamic optimization

intra-operative risk stratification
10 – point surgical outcomes score

anesthetic technique / agent
neuraxial techniques

2014; CD010108

0 – 30 day mortality

therapy intensification
667 consecutive major vascular surgery pts

66 pts suffered postoperative Tn I elevation
therapy was intensified in 43 pts (65 %)
primary endpoint: 12 mnth survival without major cardiac events

major cardiac event-free survivial

conclusions
ü evidence ?
ü complicated ?
ü implementation ?

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2014 ESC / ESA guidelines on

Stefan De Hert, MD, PhD

© 2010 Universitair Ziekenhuis Gent 2

member, 2009 ESC/ESA Task Force for Preoperative Cardiac Risk

chair, ESA Task Force on Preoperative evaluation of the adult patient

member, 2014 ESC/ESA joint task Force on Non-cardiac surgery:

© 2010 Universitair Ziekenhuis Gent 4

© 2010 Universitair Ziekenhuis Gent 9

è role of the anesthesiologists

è evaluation of surgical risk

è pre-operative risk scores

è ECG and echocardiography

è pharmacological risk reduction strategies

è intra- and postoperative anesthetic management

© 2010 Universitair Ziekenhuis Gent 12

© 2010 Universitair Ziekenhuis Gent 13

© 2010 Universitair Ziekenhuis Gent 15

emergent è intervention within 6 hrs

LOW risk è risk of MACE < 1%

© 2010 Universitair Ziekenhuis Gent 16

© 2010 Universitair Ziekenhuis Gent 17

è difficult to assign a specific risk

è invasive / less invasive procedure ?

è assumption: less invasive = less risk

© 2010 Universitair Ziekenhuis Gent 21

24 studies including > 790,000 pts

moderately good discrimination of high vs low risk for cardiac

© 2010 Universitair Ziekenhuis Gent 23

5. history of diabetes requiring insulin

6. chronic kidney disease

American College of Surgeons multicenter

© 2010 Universitair Ziekenhuis Gent 26

© 2010 Universitair Ziekenhuis Gent 27

scores provide complementary information

© 2010 Universitair Ziekenhuis Gent 28

© 2010 Universitair Ziekenhuis Gent 29

© 2010 Universitair Ziekenhuis Gent 34

© 2010 Universitair Ziekenhuis Gent 38

© 2010 Universitair Ziekenhuis Gent 39

© 2010 Universitair Ziekenhuis Gent 40

è intra-operative risk stratification

è anesthetic technique / agent

è identification of patient at risk and

© 2010 Universitair Ziekenhuis Gent 42

© 2010 Universitair Ziekenhuis Gent 45

10 – point surgical outcomes score

© 2010 Universitair Ziekenhuis Gent 46

© 2010 Universitair Ziekenhuis Gent 48

© 2010 Universitair Ziekenhuis Gent 49

© 2010 Universitair Ziekenhuis Gent 50

667 consecutive major vascular surgery pts

therapy was intensified in 43 pts (65 %)

primary endpoint: 12 mnth survival without major cardiac events

© 2010 Universitair Ziekenhuis Gent 54

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