Preoperative evaluation of Cardiovascular Diseases : Updated ESA guidelines

European Society of Anaesthesiology (ESA) has released its latest recommendations on the preoperative evaluation of the adult undergoing noncardiac surgery. The present guidelines are an update of 2011 European Society of Anaesthesiology (ESA). The purpose of the guidelines is to present recommendations based on the available relevant clinical evidence. Due to the lack of well-performed randomized studies on the topic, many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries.

For the present revision of the guidelines, ESA formed a task force comprising of members of the previous task force, ESA scientific subcommittees and volunteers from ESA and national societies who selected relevant systematic reviews with meta-analyses, randomized controlled trials, cohort studies, case-control studies and cross-sectional surveys from different electronic databases. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations.

Cardiovascular disease

Of the 200 million adults undergoing major noncardiac surgery worldwide each year, an estimated 100 million are at risk for perioperative myocardial infarction or injury and more than 10 million actually suffer major cardiac adverse events in the first 30 postoperative days. Pre-operative identification of patients at risk for developing peri-operative cardiac problems and possible medical optimization of the condition may therefore greatly improve outcome.

Key Recommendations for preoperative evaluation of Cardiovascular Diseases are as follows :

• National Surgical Quality Improvement Program (NSQIP) model or the RCRI for cardiac peri-operative risk stratification


• Consider assessment of cardiac troponins in high-risk patients, both before and 48 to 72 h after major surgery


• Selected patients with cardiac disease undergoing low and intermediate-risk noncardiac surgery may be referred by the anesthesiologist for cardiological evaluation and medical optimization


• Consider pre-operative initiation of beta-blockers in patients scheduled for high-risk surgery and who have at least two clinical risk factors or ASA status at least 3


• Use atenolol or bisoprolol as the first choice for initiation of oral beta-blockade in patients undergoing noncardiac surgery


• Discontinue aspirin therapy when control of hemostasis is anticipated to be difficult during surgery


• Consider pre-operative initiation of beta-blockers in patients who have known ischaemic heart disease or myocardial ischemia.


• Peri-operative continuation of beta-blockers in patients currently receiving this medication


• Consider brain natriuretic peptide (BNP) measurement for obtaining independent prognostic information on peri-operative and late cardiac events in high-risk patients

Respiratory disease, smoking, obstructive sleep apnea syndrome

Pulmonary complications, including pneumonia, respiratory failure, exacerbation of chronic lung disease and atelectasis, pose a clinically significant postoperative risk.

Key Recommendations:

• Routine pre-operative chest radiographs are not recommended as they rarely alter peri-operative management


• Patients with obstructive sleep apnoea syndrome should be evaluated carefully for a potentially difficult airway and that special vigilance is required in the immediate postoperative period


• Use specific questionnaires to screen for obstructive sleep apnoea syndrome when polysomnography is not available


• Pre-operative diagnostic spirometry should not be used as a general measure to predict the risk of postoperative complications in noncardiothoracic patients


• Use continuous positive airways pressure (CPAP) in patients with obstructive sleep apnoea syndrome to reduce hypoxic events


• Pre-operative IMT reduces postoperative atelectasis, pneumonia, and length of hospital stay


• There is insufficient evidence to indicate that short-term cessation (<4 weeks) of smoking decreases the rate of postoperative complications


• Smoking cessation of at least 4 weeks prior to surgery reduces postoperative complications


• Pre-operative incentive spirometry does not necessarily help in the prevention of postoperative pulmonary complications (PPCs)


• Pre-operative inspiratory muscle training (IMT) reduces postoperative atelectasis, pneumonia, and length of hospital stay

For further information click on the link: 10.1097/EJA.0000000000000817