2022 ESC Guidelines on Cardiovascular Assessment and Management of Patients Undergoing Non-Cardiac Surgery PDF

European Heart Journal (2022) 43, 3826–3924 ESC GUIDELINES https://doi.org/10.1093/eurheartj/ehac270 2022 ESC Guidelines on cardiovascular assessment and management o...

European Heart Journal (2022) 43, 3826–3924 ESC GUIDELINES https://doi.org/10.1093/eurheartj/ehac270 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery Developed by the task force for cardiovascular assessment and Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC) Authors/Task Force Members: Sigrun Halvorsen *† (Chairperson) (Norway), Julinda Mehilli *† (Chairperson) (Germany), Salvatore Cassese** (Task Force Coordinator) (Germany), Trygve S. Hall** (Task Force Coordinator) (Norway), Magdy Abdelhamid (Egypt), Emanuele Barbato (Italy/Belgium), Stefan De Hert1 (Belgium), Ingrid de Laval (Sweden), Tobias Geisler (Germany), Lynne Hinterbuchner (Austria), Borja Ibanez (Spain), Radosław Lenarczyk (Poland), Ulrich R. Mansmann (Germany), Paul McGreavy (United Kingdom), Christian Mueller (Switzerland), Claudio Muneretto (Italy), Alexander Niessner (Austria), Tatjana S. Potpara (Serbia), Arsen Ristić (Serbia), L. Elif Sade (United States of America/Turkey), Henrik Schirmer (Norway), Stefanie Schüpke (Germany), Henrik Sillesen (Denmark), Helge Skulstad (Norway), Lucia Torracca (Italy), Oktay Tutarel (Germany), Peter Van Der Meer (Netherlands), Wojtek Wojakowski (Poland), Kai Zacharowski1 (Germany), and ESC Scientific Document Group * Corresponding authors: Sigrun Halvorsen, Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway, and University of Oslo, Oslo, Norway. Tel.: +47 91317460. E-mail: [email protected]. Julinda Mehilli, Department: Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany, Klinikum der Universität München, Ludwig-Maximilians-Universität and German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany. Tel.: +49 871 4042782. E-mail: [email protected] † The two chairpersons contributed equally to the document and are joint corresponding authors. ** The two Task Force Coordinators contributed equally to the document Author/Task Force Member affiliations: listed in author information. 1 Representing the European Society of Anaesthesiology and Intensive Care (ESAIC) ESC Clinical Practice Guidelines (CPG) Committee listed in the Appendix. ESC subspecialty communities having participated in the development of this document: Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), and Heart Failure Association (HFA). Councils: Council of Cardio-Oncology and Council on Valvular Heart Disease. Working Groups: Adult Congenital Heart Disease, Aorta and Peripheral Vascular Diseases, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, and Thrombosis. Patient Forum The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal, and the party authorized to handle such permissions on behalf of the ESC ([email protected]). ESC Guidelines 3827 Document-Reviewers: Juhani Knuuti, (CPG Review Coordinator) (Finland), Steen Dalby Kristensen, (CPG Review Coordinator) (Denmark), Victor Aboyans (France), Ingo Ahrens (Germany), Sotiris Antoniou (United Kingdom), Riccardo Asteggiano (Italy), Dan Atar (Norway), Andreas Baumbach (United Kingdom), Helmut Baumgartner (Germany), Michael Böhm (Germany), Michael A. Borger (Germany), Hector Bueno (Spain), Jelena Čelutkienė (Lithuania), Alaide Chieffo (Italy), Maya Cikes (Croatia), Harald Darius (Germany), Victoria Delgado (Spain), Philip J. Devereaux (Canada), David Duncker (Germany), Volkmar Falk (Germany), Laurent Fauchier (France), Gilbert Habib (France), David Hasdai (Israel), Kurt Huber (Austria), Bernard Iung (France), Tiny Jaarsma (Sweden), Aleksandra Konradi (Russian Federation), Konstantinos C. Koskinas (Switzerland), Dipak Kotecha (United Kingdom), Ulf Landmesser (Germany), Basil S. Lewis (Israel), Ales Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Michael Maeng (Denmark), Stéphane Manzo-Silberman (France), Richard Mindham (United Kingdom), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Steffen E. Petersen (United Kingdom), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Antti Saraste (Finland), Dirk Sibbing (Germany), Jolanta Siller-Matula (Austria), Marta Sitges (Spain), Ivan Stankovic (Serbia), Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 Rob F. Storey (United Kingdom), Jurrien ten Berg (Netherlands), Matthias Thielmann (Germany), and Rhian M. Touyz (Canada/United Kingdom) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the guidelines. The report is also available on the ESC website www.escardio.org/Guidelines See the European Heart Journal online for supplementary data that include background information and detailed discussion of the data that have provided the basis of the guidelines. Click here to access the corresponding ESC CardioMed chapters. Keywords Guidelines Non-cardiac surgery Pre-operative cardiac risk assessment Pre-operative cardiac testing Biomarkers Pre-operative coronary artery revascularization Peri-operative cardiac management Anti-thrombotic therapy Peri-operative beta-blockers Pre-operative treatment of valvular disease Peri-operative treatment of arrhythmias Post-operative cardiac surveillance Peri-operative myocardial injury/infarction 3.2.1.1. Vascular and endovascular procedures................... 3843 Table of contents 3.2.1.2. Video-assisted non-cardiac surgery........................... 3843 1. Preamble........................................................................................................ 3832 3.3. Patient-related risk............................................................................ 3843 2. Introduction................................................................................................. 3834 3.3.1. Initial assessment....................................................................... 3843 2.1. What is new........................................................................................ 3834 3.3.1.1. Patients aged ,65 years without a history of 2.2. The magnitude of the problem................................................... 3839 cardiovascular disease or cardiovascular risk factors........ 3843 2.3. Change in demographics................................................................ 3840 3.3.1.2. Patients aged ≥65 years or with cardiovascular risk 2.4. Purpose.................................................................................................. 3840 factors.................................................................................................... 3843 2.5. The outcomes we want to prevent.......................................... 3841 3.3.1.3. Patients with established cardiovascular disease. 3844 3. Clinical risk evaluation.............................................................................. 3841 3.3.2. Patients with murmurs, chest pain, dyspnoea, or 3.1. Surgery-related risk.......................................................................... 3841 peripheral oedema............................................................................... 3845 3.1.1. Timing of surgery...................................................................... 3842 3.3.2.1. Murmurs............................................................................... 3845 3.2. Type of surgical approach............................................................. 3842 3.3.2.2. Chest pain............................................................................ 3845 3.2.1. Laparoscopy................................................................................ 3842 3.3.2.3. Dyspnoea.............................................................................. 3845 Disclaimer: The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, particularly in relation to good use of health care or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, and in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. The ESC Guidelines do not exempt health profes- sionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. © The European Society of Cardiology 2022. All rights reserved. For permissions please e-mail: [email protected] 3828 ESC Guidelines 3.3.2.4. Peripheral oedema........................................................... 3845 5.3.2.2.6. When to restart non-vitamin K antagonist oral 3.4. Timing of adequate risk evaluation............................................ 3846 anticoagulants after interventions......................................... 3868 3.5. Avoidance or allowance for surgery in the individual patient 3846 5.3.2.3. Combination therapy (antiplatelet and 3.6. The patient perspective.................................................................. 3846 anticoagulant)...................................................................................... 3868 4. Pre-operative assessment tools........................................................... 3847 5.4. Peri-operative thromboprophylaxis.......................................... 3869 4.1. Risk scores............................................................................................ 3847 5.5. Patient blood management........................................................... 3869 4.1.1. General risk calculators.......................................................... 3847 5.5.1. Pre-operative anaemia—diagnosis and treatment..... 3870 4.1.2. Frailty.............................................................................................. 3849 5.5.2. Bleeding and reduction of iatrogenic diagnostic/ 4.2. Functional capacity............................................................................ 3849 surgery-related blood loss................................................................ 3870 4.3. Electrocardiography......................................................................... 3850 5.5.3. Optimal blood component use with patient-centred 4.4. Biomarkers........................................................................................... 3850 clinical decision support..................................................................... 3871 4.5. Non-invasive and invasive procedures..................................... 3851 6. Specific diseases.......................................................................................... 3871 4.5.1. Resting transthoracic echocardiography......................... 3851 6.1. Coronary artery disease................................................................. 3871 Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 4.5.2. Stress tests................................................................................... 3852 6.1.1. Risk for patients with coronary artery disease............ 3871 4.5.2.1. Exercise stress test........................................................... 3852 6.1.2. Pre-operative risk assessment and management........ 3872 4.5.2.2. Stress imaging..................................................................... 3852 6.1.3. Revascularization strategies.................................................. 3872 4.5.3. Angiography................................................................................ 3853 6.1.3.1. Chronic coronary syndromes...................................... 3872 4.5.3.1. Coronary computed tomography angiography... 3853 6.1.3.2. Acute coronary syndromes.......................................... 3872 4.5.3.2. Invasive coronary angiography.................................... 3853 6.2. Chronic heart failure........................................................................ 3874 5. General risk-reduction strategies........................................................ 3854 6.2.1. Risk for patients with heart failure.................................... 3874 5.1. Cardiovascular risk factors and lifestyle interventions...... 3854 6.2.2. Pre- and post-operative management strategies........ 3874 5.2. Pharmacological................................................................................. 3854 6.2.3. Hypertrophic obstructive cardiomyopathy................... 3875 5.2.1. Beta-blockers.............................................................................. 3854 6.2.4. Patients with ventricular assist devices undergoing 5.2.2. Amiodarone................................................................................ 3855 non-cardiac surgery.............................................................................. 3875 5.2.3. Statins............................................................................................ 3855 6.3. Valvular heart disease...................................................................... 3875 5.2.4. Renin–angiotensin–aldosterone system inhibitors..... 3855 6.3.1. Risk for patients with valvular heart disease................. 3875 5.2.5. Calcium channel blockers...................................................... 3855 6.3.2. Pre-operative management strategies and risk- 5.2.6. Alpha-2 receptor agonists.................................................... 3856 reduction strategy................................................................................. 3876 5.2.7. Diuretics....................................................................................... 3856 6.3.2.1. Aortic valve stenosis........................................................ 3876 5.2.8. Ivabradine..................................................................................... 3856 6.3.2.2. Mitral valve stenosis......................................................... 3877 5.2.9. Sodium–glucose co-transporter-2 inhibitors................ 3856 6.3.2.3. Aortic valve regurgitation.............................................. 3878 5.3. Peri-operative handling of antithrombotic agents............... 3857 6.3.2.4. Mitral valve regurgitation............................................... 3878 5.3.1. Antiplatelets................................................................................ 3857 6.3.2.5. Patients with prosthetic valve(s)................................ 3878 5.3.1.1. Single antiplatelet therapy............................................. 3857 6.3.2.6. Prophylaxis of infective endocarditis........................ 3878 5.3.1.2. Dual antiplatelet therapy............................................... 3860 6.4. Known or newly diagnosed arrhythmias................................ 3879 5.3.1.3. De-escalation of antiplatelet effect............................ 3862 6.4.1. Peri-operative management—general measures........ 3879 5.3.1.4. Platelet function guided peri-operative 6.4.2. Supraventricular arrhythmias............................................... 3879 management of antiplatelet therapy......................................... 3862 6.4.3. Atrial fibrillation/flutter........................................................... 3879 5.3.2. Oral anticoagulants.................................................................. 3863 6.4.4. Ventricular arrhythmias......................................................... 3879 5.3.2.1. Vitamin K antagonists...................................................... 3863 6.4.5. Bradyarrhythmias...................................................................... 3881 5.3.2.1.1. Vitamin K antagonists in patients with 6.4.6. Management of patients with cardiac implantable mechanical heart valves............................................................. 3863 electronic devices.................................................................................. 3881 5.3.2.1.2. Vitamin K antagonists for atrial fibrillation/ 6.5. Adult congenital heart disease..................................................... 3882 venous thromboembolism....................................................... 3864 6.6. Pericardial diseases........................................................................... 3883 5.3.2.1.3. Restarting vitamin K antagonists after invasive 6.7. Pulmonary disease and pulmonary arterial hypertension 3884 procedures or surgery............................................................... 3864 6.7.1. Pulmonary disease.................................................................... 3884 5.3.2.1.4. Reversal of vitamin K antagonists...................... 3864 6.7.2. Pulmonary arterial hypertension........................................ 3884 5.3.2.2. Non-vitamin K antagonist oral anticoagulants...... 3864 6.8. Arterial hypertension....................................................................... 3885 5.3.2.2.1. Unplanned surgery in patients on non-vitamin 6.9. Peripheral artery disease................................................................ 3886 K antagonist oral anticoagulants and reversal for 6.9.1. Peripheral artery disease and non-vascular non-cardiac emergency procedures.............................................................. 3864 surgery....................................................................................................... 3886 5.3.2.2.2. Planned interventions in patients on non- 6.9.2. Peripheral artery disease and vascular non-cardiac vitamin K oral anticoagulants.................................................. 3866 surgery....................................................................................................... 3886 5.3.2.2.3. Bridging......................................................................... 3866 6.10. Cerebrovascular disease.............................................................. 3887 5.3.2.2.4. Laboratory testing before surgery.................... 3866 6.11. Renal disease..................................................................................... 3887 5.3.2.2.5. Considerations for specific procedures.......... 3867 6.12. Obesity................................................................................................ 3888 ESC Guidelines 3829 6.13. Diabetes.............................................................................................. 3889 Recommendation Table 9 — Recommendations for stress imaging 3853 6.14. Cancer................................................................................................. 3889 Recommendation Table 10 — Recommendations for coronary 6.15. Coronavirus disease 2019........................................................... 3889 angiography........................................................................................................ 3853 7. Peri-operative monitoring and anaesthesia.................................... 3890 Recommendation Table 11 — Recommendations for lifestyle and 7.1. Peri-operative monitoring............................................................. 3890 cardiovascular risk factors........................................................................... 3854 7.2. Anaesthesia.......................................................................................... 3891 Recommendation Table 12 — Recommendations for 7.2.1. Intra-operative haemodynamics......................................... 3891 pharmacological treatment......................................................................... 3856 7.2.2. Choice of anaesthetic agent................................................. 3892 Recommendation Table 13 — Recommendations for use of 7.3. Locoregional techniques................................................................ 3892 antiplatelet therapy in patients undergoing non-cardiac surgery 3862 7.4. Peri-operative goal-directed haemodynamic therapy....... 3893 Recommendation Table 14 — Recommendations for 7.5. Post-operative management......................................................... 3893 interruption and resumption of anticoagulants in patients 8. Peri-operative cardiovascular complications.................................. 3893 undergoing non-cardiac surgery............................................................... 3868 8.1. Peri-operative myocardial infarction/injury............................ 3894 Recommendation Table 15 — Recommendations for Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 8.2. Spontaneous myocardial infarction (after day 2)................ 3897 thromboprophylaxis...................................................................................... 3869 8.3. Takotsubo syndrome....................................................................... 3897 Recommendation Table 16 — Recommendations for intra- and 8.4. Acute heart failure............................................................................ 3897 post-operative complications associated with anaemia................. 3870 8.5. Venous thromboembolism........................................................... 3897 Recommendation Table 17 — Recommendations for intra- and 8.6. Atrial fibrillation and other relevant arrhythmias................ 3897 post-operative complications associated with blood loss............. 3871 8.6.1. Prevention of post-operative atrial fibrillation............. 3897 Recommendation Table 18 — Recommendations for intra- and 8.6.2. Management of post-operative atrial fibrillation......... 3898 post-operative complications associated with allogeneic blood 8.6.2.1. Rate and/or rhythm control......................................... 3898 transfusion.......................................................................................................... 3871 8.6.2.2. Prevention of atrial fibrillation-related Recommendation Table 19 — Recommendations for the timing thromboembolic complications.................................................. 3899 of non-cardiac surgery and revascularization in patients with 8.7. Peri-operative stroke....................................................................... 3899 known coronary artery disease................................................................ 3874 9. Key messages............................................................................................... 3900 Recommendation Table 20 — Recommendations for 10. Gaps in evidence...................................................................................... 3900 management of heart failure in patients undergoing non-cardiac 11. Sex differences......................................................................................... 3901 surgery................................................................................................................. 3875 12. ‘What to do’ and ‘what not to do’ messages from the Recommendation Table 21 — Recommendations for Guidelines........................................................................................................... 3901 management of valvular heart disease in patients undergoing 13. Quality indicators.................................................................................... 3906 non-cardiac surgery........................................................................................ 3878 14. Central illustration.................................................................................. 3906 Recommendation Table 22 — Recommendations 15. Supplementary data................................................................................ 3907 for management of known or newly diagnosed arrhythmias...... 3880 16. Data availability statement................................................................... 3907 Recommendation Table 23 — Recommendations for 17. Author information................................................................................ 3907 management of bradyarrhythmia and patients carrying cardiac 18. Appendix..................................................................................................... 3907 implantable devices........................................................................................ 3882 19. References.................................................................................................. 3908 Recommendation Table 24 — Recommendations for management of patients with adult congenital heart disease Tables of Recommendations undergoing non-cardiac surgery............................................................... 3883 Recommendation Table 25 — Recommendations for pericardial Recommendation Table 1 — Recommendations for selection of diseases................................................................................................................ 3884 surgical approach and impact on risk..................................................... 3843 Recommendation Table 26 — Recommendations for patients Recommendation Table 2 — Recommendations for all patients with pulmonary arterial hypertension undergoing non-cardiac scheduled for non-cardiac surgery.......................................................... 3845 surgery................................................................................................................. 3885 Recommendation Table 3 — Recommendations for patients Recommendation Table 27 — Recommendations for aged ,65 years without signs, symptoms, or history of pre-operative management of hypertension...................................... 3886 cardiovascular disease................................................................................... 3845 Recommendation Table 28 — Recommendations for Recommendation Table 4 — Recommendations for management of patients with peripheral artery disease pre-operative assessment in patients with previously unknown and/or abdominal aortic aneurysm undergoing non-cardiac murmur, angina, dyspnoea, or peripheral oedema.......................... 3845 surgery......................................................................................................... 3887 Recommendation Table 5 — Recommendations for patient Recommendation Table 29 — Recommendations for information........................................................................................................ 3847 management of patients with suspected or established carotid Recommendation Table 6 — Recommendations for artery disease undergoing non-cardiac surgery................................. 3887 pre-operative assessment of frailty and functional capacity......... 3849 Recommendation Table 30 — Recommendations for Recommendation Table 7 — Recommendations for management of patients with renal disease undergoing pre-operative risk assessment—electrocardiography and non-cardiac surgery........................................................................................ 3888 biomarkers......................................................................................................... 3851 Recommendation Table 31 — Recommendations for Recommendation Table 8 — Recommendations for management of patients with obesity undergoing non-cardiac transthoracic echocardiography............................................................... 3852 surgery................................................................................................................. 3888 3830 ESC Guidelines Recommendation Table 32 — Recommendations for Figure 10 Timing of last non-vitamin K antagonist oral anticoagulant management of patients with diabetes mellitus undergoing dose before elective NCS according to renal function...................... 3866 non-cardiac surgery........................................................................................ 3889 Figure 11 Suggested strategy for potential reversal of non-vitamin Recommendation Table 33 — Recommendations for K oral anticoagulants effect........................................................................ 3867 peri-operative monitoring and anaesthesia......................................... 3893 Figure 12 Management of patients with acute or chronic coronary Recommendation Table 34 — Recommendations for syndrome scheduled for non-cardiac surgery.................................... 3873 peri-operative cardiovascular complications....................................... 3899 Figure 13 Management of patients with severe aortic valve stenosis scheduled for non-cardiac surgery........................................ 3876 Figure 14 Management of patients with secondary mitral valve List of tables regurgitation scheduled for non-cardiac surgery.............................. 3877 Table 1 Classes of recommendations.................................................... 3833 Figure 15 Optimal location of return electrode during unipolar Table 2 Levels of evidence.......................................................................... 3833 electrosurgery in patients with cardiac implantable electronic Table 3 New concepts and sections in the current guidelines... 3834 devices, depending on the surgery site.................................................. 3882 Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 Table 4 What is new..................................................................................... 3834 Figure 16 Pathophysiological approach to address intra-operative Table 4A New recommendations........................................................... 3834 hypotension....................................................................................................... 3892 Table 4B Revised recommendations...................................................... 3838 Figure 17 Factors associated with peri-operative cardiovascular Table 5 Surgical risk estimate according to type of surgery or complications. SNS, sympathetic nervous system............................ 3894 intervention....................................................................................................... 3842 Figure 18 Differential diagnosis of elevated post-operative cardiac Table 6 Risk score calculators................................................................... 3848 troponin concentrations.............................................................................. 3895 Table 7 Pharmacokinetic and pharmacodynamic characteristics of Figure 19 Systematic work-up (aetiology) and therapy of antiplatelets........................................................................................................ 3857 peri-operative myocardial infarction/injury.......................................... 3896 Table 8 Pharmacokinetic and pharmacodynamic characteristics of Figure 20 Prevention and management of post-operative atrial oral anticoagulants.......................................................................................... 3858 fibrillation............................................................................................................ 3898 Table 9 Bleeding risk according to type of non-cardiac surgery 3858 Figure 21 Central illustration: the complex interplay between the Table 10 Laboratory parameters for the diagnosis of absolute intrinsic risk of surgery and the patient risk of peri-operative iron-deficiency anaemia................................................................................ 3870 cardiovascular complications..................................................................... 3906 Table 11 Peri-operative approach to patients with ventricular assist devices undergoing non-cardiac surgery................................... 3875 Abbreviations and acronyms Table 12 Peri-operative management of patients with arrhythmias 3880 Table 13 Risk stratification for non-cardiac surgery in adults with AAA Abdominal aortic aneurysm congenital heart disease............................................................................... 3883 AAD Antiarrhythmic drug Table 14 Patient-related and surgery-related factors to be ACEI Angiotensin-converting-enzyme considered when assessing peri-operative risk in patients with inhibitor pulmonary arterial hypertension.............................................................. 3885 ACHD Adults with congenital heart disease Table 15 Factors that could influence peri-operative risk during ACS Acute coronary syndrome cancer surgery and preventive strategies............................................. 3890 ACS NSQIP American College of Surgery National Surgical Quality Improvement Program Atrial fibrillation List of figures AF AKI Acute kidney injury Figure 1 Total risk is an interaction of patient-related and aPTT Activated partial thromboplastin time surgery-related risk........................................................................................ 3841 AR Aortic valve regurgitation Figure 2 Pre-operative assessment before non-cardiac surgery 3844 ARB Angiotensin receptor blocker Figure 3 Examples of questions and concerns expressed by ARNI Angiotensin receptor neprilysin inhibitor patients................................................................................................................ 3847 AS Aortic valve stenosis Figure 4 Recommended measurements to assess and detect the ASA Acetylsalicylic acid risk of post-operative cardiac complications...................................... 3850 ASA–PS American Society of Anesthesiology Figure 5 Recommendations for management of antiplatelet Physical Status therapy in patients undergoing non-cardiac surgery....................... 3859 ASCVD Atherosclerotic cardiovascular disease Figure 6 P2Y12 inhibitor interruption after percutaneous AUB-HAS2 American University of Beirut coronary intervention before elective non-cardiac surgery......... 3860 (AUB)-HAS2 Figure 7 Bridging with intravenous antiplatelet agents. ASA, AUC Area under curve acetylsalicylic acid; FU, follow-up; LD, loading dose; NCS, AVR Aortic valve replacement non-cardiac surgery; o.d., once a day...................................................... 3861 BAV Balloon aortic valvuloplasty Figure 8 Recommendations for management of oral BCSH British Committee for Standards in anticoagulation therapy in patients undergoing non-cardiac Haematology surgery................................................................................................................. 3863 b.i.d. Bis in die (twice a day) Figure 9 Peri-operative management of non-vitamin K antagonist BTKi Bruton tyrosine kinase inhibitors oral anticoagulant according to the periprocedural risk of bleeding 3865 BMI Body mass index ESC Guidelines 3831 BMS Bare metal stent EDKA Euglycaemic diabetic ketoacidosis BNP B-type natriuretic peptide eGFR Estimated glomerular filtration rate BP Blood pressure EMI Electromagnetic interference b.p.m. Beats per minute EORP EURObservational Research BSA Body surface area Programme CABG Coronary artery bypass graft ESA European Society of Anaesthesiology CAD Coronary artery disease ESC European Society of Cardiology CARP Coronary Artery Revascularization ESH European Society of Hypertension Prophylaxis (trial) ESTS European Society of Thoracic CAS Carotid artery stenting Surgeons CASS Coronary Artery Surgery Study ESVS European Society for Vascular Surgery CCB Calcium channel blocker EuSOS European Surgical Outcomes Study CCS Chronic coronary syndrome EVAR Endovascular abdominal aortic aneurysm Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 CCTA Coronary computed tomography repair angiography FDA US Food and Drug Administration CEA Carotid endarterectomy FFR Fractional flow reserve CHA2DS2-VASc Congestive heart failure, hypertension, FIIa Factor IIa age ≥75 years, diabetes mellitus, stroke, FOCUS Focused cardiac ultrasound vascular disease, age 65–74 years, sex FXa Factor Xa category (female) GDMT Guideline-directed medical therapy CI Confidence interval GFR Glomerular filtration rate CIED Cardiac implantable electronic device HbA1c Glycated haemoglobin CK Creatinine kinase HF Heart failure CKD Chronic kidney disease HIP-ATTACK HIP Fracture Accelerated Surgical CKD-EPI Chronic Kidney Disease Epidemiology TreaTment And Care tracK (trial) Collaboration HR Hazard ratio Cmax Maximum serum concentration hs-cTn High-sensitivity cardiac troponin CMR Cardiac magnetic resonance i.v. Intravenous COAPT Cardiovascular Outcomes Assessment ICA Invasive coronary angiography of the MitraClip Percutaneous Therapy ICD Implantable cardioverter–defibrillator for Heart Failure Patients with ICU Intensive care unit Functional Mitral Regurgitation (trial) ID Iron deficiency COPD Chronic obstructive pulmonary disease IHD Ischaemic heart disease CORIDA Per-procedural Concentration of Direct INR International normalized ratio Oral Anticoagulants (trial) ISCHEMIA International Study of Comparative Coronary CTA VISION Coronary Computed Tomographic Health Effectiveness with Medical and Angiography and Vascular Events in Invasive Approaches (trial) Noncardiac Surgery Patients Cohort iwFR Instantaneous wave-free ratio Evaluation (trial) KDIGO Kidney Disease: Improving Global COVID-19 Coronavirus disease 2019 Outcomes CPET Cardiopulmonary exercise testing LD Loading dose CRF Cardiorespiratory fitness LMWH Low molecular weight heparin CRT Cardiac resynchronization therapy LOAD Lowering the Risk of Operative CT Computed tomography Complications Using Atorvastatin cTn T/I Cardiac troponin T/I Loading Dose (trial) CTO Chronic total occlusion LoE Level of evidence CV Cardiovascular LV Left ventricular CVD Cardiovascular disease LVEF Left ventricular ejection fraction DAPT Dual antiplatelet therapy LVESD Left ventricular end-systolic diameter DASI Duke Activity Status Index LVESDi Left ventricular end-systolic dimension DES Drug-eluting stent index DM Diabetes mellitus MACE Major adverse cardiovascular event DSE Dobutamine stress echocardiography MET Metabolic equivalent dTT Diluted thrombin time METS Measurement of Exercise Tolerance EACTS European Association for before Surgery (trial) Cardio-Thoracic Surgery MHV Mechanical heart valve ECG Electrocardiographic/electrocardiogram MI Myocardial infarction 3832 ESC Guidelines MINS Myocardial injury following non-cardiac TTE Transthoracic echocardiography surgery UFH Unfractionated heparin MR Mitral valve regurgitation ULN Upper limit of normal MS Mitral valve stenosis VAD Ventricular assist device NCS Non-cardiac surgery VATS Video-assisted thoracic surgery NOAC Non-vitamin K antagonist oral VEGFi Vascular endothelial grow factor anticoagulant inhibitor NSAID Non-steroidal anti-inflammatory drug VF Ventricular fibrillation NSTE-ACS Non-ST-segment elevation acute VHD Valvular heart disease coronary syndrome VISION Vascular Events in Noncardiac Surgery NT-proBNP N-terminal pro-B-type natriuretic Patients Cohort Evaluation (trial) peptide VKA Vitamin K antagonist NYHA New York Heart Association VKORC1 Vitamin K epoxide reductase complex 1 Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 OAC Oral anticoagulant VO2 Oxygen consumption o.d. Omnie die (once a day) VT Ventricular tachycardia OR Odds ratio VTE Venous thromboembolism OSA Obstructive sleep apnoea WHA World Health Assembly PA Pulmonary artery WPW Wolff–Parkinson–White PAD Peripheral artery disease PAH Pulmonary arterial hypertension PAUSE Perioperative Anticoagulant Use for 1. Preamble Surgery Evaluation (trial) Guidelines summarize and evaluate available evidence, with the aim PBM Patient Blood Management of assisting health professionals in proposing the best management PCC Prothrombin complex concentrate strategies for an individual patient with a given condition. PCI Percutaneous coronary intervention Guidelines and their recommendations should facilitate decision- PE Pulmonary embolism making of health professionals in their daily practice. Guidelines, PMC Percutaneous mitral commissurotomy however, are not a substitute for the patient’s relationship with their PMI Peri-operative myocardial infarction/ practitioner. The final decisions concerning an individual patient must injury be made by the responsible health professional(s), based on what POISE PeriOperative ISchemic Evaluation Trial they consider to be the most appropriate in the circumstances. PPC Prothrombin complex concentrate These decisions are made in consultation with the patient and care- PT Prothrombin time giver as appropriate. PVC Premature ventricular contractions Guidelines are intended for use by health professionals. To en- QI Quality indicator sure that all users have access to the most recent recommenda- RAAS Renin−angiotensin−aldosterone system tions, the European Society of Cardiology (ESC) makes its RBC Red blood cell guidelines freely available. The ESC warns readers that the technical RCRI Revised Cardiac Risk Index language may be misinterpreted and declines any responsibility in RCT Randomized controlled trial this respect. RF Radiofrequency Many guidelines have been issued in recent years by the ESC. rHuEPO Recombinant human erythropoietin Because of their impact on clinical practice, quality criteria for the de- RR Relative risk velopment of guidelines have been established in order to make all RV Right ventricular decisions transparent to the user. The recommendations for formu- SAPT Single antiplatelet therapy lating and issuing ESC Guidelines can be found on the ESC website SARS-CoV-2 Severe acute respiratory syndrome (https://www.escardio.org/Guidelines). The ESC Guidelines re- coronavirus 2 present the official position of the ESC on a given topic and are regu- SAVR Surgical aortic valve replacement larly updated. SCD Sudden cardiac death In addition to the publication of Clinical Practice Guidelines, the SGLT-2 Sodium–glucose co-transporter-2 ESC carries out the EURObservational Research Programme of SORT Surgical Outcome Risk Tool international registries of cardiovascular diseases and interven- SPAP Systolic pulmonary artery pressure tions, which are essential to assess diagnostic/therapeutic pro- STEMI ST-segment elevation myocardial cesses, use of resources, and adherence to guidelines. These infarction registries aim to provide a better understanding of medical prac- SVT Supraventricular tachycardia tice in Europe and around the world, and are based on high-quality TAVI Transcatheter aortic valve implantation data collected during routine clinical practice. Furthermore, the TEE Transoesophageal echocardiography ESC develops sets of quality indicators (QIs)—which are tools TEER Transcatheter edge-to-edge repair to evaluate the level of implementation of the guidelines and TIA Transient ischaemic attack may be used by the ESC, hospitals, healthcare providers, and ESC Guidelines 3833 professionals to measure clinical practice, and in educational pro- options were weighed and scored according to pre-defined scales, as grammes—alongside the key messages from the guidelines, to im- outlined below. The Task Force followed the ESC voting procedures. prove quality of care and clinical outcomes. All recommendations subject to a vote achieved at least 75% among The members of this Task Force were selected by the ESC to re- voting members. present professionals involved with the medical care of patients with The experts of the writing and reviewing panels provided declar- this pathology. The selection procedure aimed to ensure that there is ation of interest forms for all relationships that might be perceived as a representative mix of members, predominantly from across the real or potential sources of conflicts of interest. Their declarations of whole of the ESC region and from relevant ESC Subspecialty interest were reviewed according to the ESC declaration of interest Communities. Consideration was given to diversity and inclusion, rules and can be found on the ESC website (http://www.escardio.org/ notably with respect to gender and country of origin. A critical evalu- Guidelines) and have been compiled in a report and simultaneously ation of diagnostic and therapeutic procedures was performed, in- published in a supplementary document to the guidelines. This pro- cluding assessment of the risk–benefit ratio. The level of evidence cess ensures transparency and prevents potential biases in the devel- and the strength of the recommendation of particular management opment and review processes. Any changes in declarations of Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 Table 1 Classes of recommendations Definition Wording to use Classes of recommendations Class I Evidence and/or general agreement Is recommended or is indicated that a given treatment or procedure is beneficial, useful, effective. Class II Conflicting evidence and/or a divergence of opinion about the usefulness/ efficacy of the given treatment or procedure. Class IIa Weight of evidence/opinion is in Should be considered favour of usefulness/efficacy. Class IIb Usefulness/efficacy is less well May be considered established by evidence/opinion. Class III Evidence or general agreement that the Is not recommended given treatment or procedure is not © ESC 2022 ©ESC 2022 useful/effective, and in some cases may be harmful. Table 2 Levels of evidence Level of Data derived from multiple randomized clinical trials evidence A or meta-analyses. Level of Data derived from a single randomized clinical trial evidence B or large non-randomized studies. Level of Consensus of opinion of the experts and/or small studies, © ESC 2022 ©ESC 2022 evidence C retrospective studies, registries. 3834 ESC Guidelines interest that arose during the writing period were notified to the ESC and updated. The Task Force received its entire financial sup- 2. Introduction port from the ESC without any involvement from the healthcare 2.1. What is new industry. The ESC CPG Committee supervises and coordinates the prepar- ation of new guidelines. The Committee is also responsible for the Table 3 New concepts and sections in the current approval process of these guidelines. The ESC Guidelines undergo guidelines extensive review by the CPG Committee and external experts, in- A new flowchart for general assessment of patients before NCS. cluding a mix of members from across the whole of the ESC region A new section on pre-operative assessment of patients with newly and from relevant ESC Subspecialty Communities and National detected murmurs, dyspnoea, oedema, or angina. Cardiac Societies. After appropriate revisions, the guidelines are A new section on the patient perspective. signed-off by all the experts involved in the Task Force. The finalized A new section on assessment of frailty. document is signed-off by the CPG Committee for publication in the Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 A revised and expanded focus on use of biomarkers in NCS European Heart Journal. The guidelines are developed after careful A revised and expanded section on peri-operative management of consideration of the scientific and medical knowledge and the evi- antiplatelet therapy. dence available at the time of their writing. A revised and expanded section on peri-operative management of The task of developing the ESC Guidelines also includes creating oral anticoagulants. educational tools and implementating programmes for the recom- mendations, including condensed pocket guidelines versions, sum- A new section on peri-operative thromboprophylaxis. mary slides, summary cards for non-specialists, and an electronic A dedicated section on patient blood management. version for digital applications (smartphones, etc.). These versions A new section on management of cardiovascular risk in patients with are abridged and thus, for more detailed information, the user should cancer undergoing NCS. © ESC 2022 always access the full text version of the guidelines, which is A small section on NCS in patients with recent COVID-19. freely available via the ESC website and the European Heart Journal. A new section on diagnosis and management of post-operative The National Cardiac Societies of the ESC are encouraged to complications during NCS. endorse, adopt, translate, and implement all ESC Guidelines. COVID-19, coronavirus 2019; NCS, non-cardiac surgery Implementation programmes are needed because it has been shown © ESC 2022 that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations. Health professionals are encouraged to take the ESC Guidelines Table 4 What is new fully into account when exercising their clinical judgment, and in de- termining and implementing preventive, diagnostic, or therapeutic Table 4A New recommendations medical strategies. However, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health profes- Recommendation Class sionals to make appropriate and accurate decisions in considering each patient’s health condition and in consulting with that patient Clinical risk evaluation—Section 3 or the patient’s caregiver where appropriate and/or necessary. It is Patients scheduled for NCS also the health professional’s responsibility to verify the rules and In all patients scheduled for NCS, an accurate history, and regulations applicable in each country to drugs and devices at the I clinical examination are recommended. time of prescription and, where appropriate, to respect the ethical It is recommended to perform a pre-operative risk assessment, rules of their profession. I ideally at the same time as the NCS is proposed. Off-label use of medication may be presented in these guidelines If time allows, it is recommended to optimize if a sufficient level of evidence shows that it can be considered med- guideline-recommended treatment of CVD and CV risk factors I ically appropriate to a given condition and if patients could benefit before NCS. from the recommended therapy. However, the final decisions con- Endovascular or video-assisted procedures should be cerning an individual patient must be made by the responsible health considered for patients with high CV risk undergoing vascular IIa professional, giving special consideration to: or pulmonary surgery. (a) the specific situation of the patient. In this respect, it is specified Patients aged ,65 years without signs, symptoms, or history that, unless otherwise provided for by national regulations, off- of CVD label use of medication should be limited to situations where it In patients with a family history of genetic cardiomyopathy, it is is in the patient’s interest to do so, with regard to the quality, recommended to perform an ECG and TTE before NCS, I safety, and efficacy of care, and only after the patient has been regardless of age and symptoms. informed and provided consent; In patients aged 45–65 years without signs, symptoms, or (b) and country-specific health regulations, indications by govern- history of CVD, ECG and biomarkers should be considered IIa mental drug regulatory agencies, and the ethical rules to which before high-risk NCS. health professionals are subject, where applicable. Continued ESC Guidelines 3835 Pre-operative assessment in patients with a newly detected Coronary angiography murmur, chest pain, dyspnoea, or peripheral oedema CCTA should be considered to rule out CAD in patients with In patients with a newly detected murmur and symptoms or suspected CCS or biomarker-negative NSTE-ACS in case of I signs of CVD, TTE is recommended before NCS. low-to-intermediate clinical likelihood of CAD, or in patients IIa In patients with a newly detected murmur suggesting clinically unsuitable for non-invasive functional testing undergoing significant pathology, TTE is recommended before high-risk I non-urgent, intermediate-, and high-risk NCS. NCS. General risk-reduction strategies—Section 5 In patients with a newly detected murmur, but without other Cardiovascular risk factors and lifestyle interventions signs or symptoms of CVD, TTE should be considered before IIa Smoking cessation.4 weeks before NCS is recommended to moderate and high-risk NCS. I reduce post-operative complications and mortality. If a patient scheduled for elective NCS has chest pain or other I Control of CV risk factors—including blood pressure, symptoms suggestive of undetected CAD, further diagnostic I Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 dyslipidaemia, and diabetes—is recommended before NCS. work-up before NCS is recommended. If a patient in need of acute NCS also has chest pain or other Pharmacological treatment symptoms suggestive of undetected CAD, a multidisciplinary For patients on diuretics to treat hypertension, transient I assessment approach is recommended to choose the discontinuation of diuretics on the day of NCS should be IIa treatment with lowest total risk for the patient. considered. In patients with dyspnoea and/or peripheral oedema, an ECG It should be considered to interrupt SGLT-2 inhibitor therapy IIa and an NT-proBNP/BNP test is indicated before NCS, unless I for at least 3 days before intermediate- or high-risk NCS. there is a certain non-cardiac explanation. Antiplatelets In patients with dyspnoea and/or peripheral oedema and For patients undergoing high bleeding risk surgery (e.g. I elevated NT-proBNP/BNP, TTE is recommended before NCS. intracranial, spinal neurosurgery, or vitreoretinal eye surgery), I Patient information it is recommended to interrupt aspirin for at least 7 days It is recommended to give patients individualized instructions pre-operatively. for pre-operative and post-operative changes in medication, in I In high-risk patients with a recent PCI (e.g. STEMI patients or verbal and written formats with clear and concise directions. high-risk NSTE-ACS patients), a DAPT duration of at least 3 IIa It should be considered to set up a structured information list months should be considered before time-sensitive NCS. (e.g. a checklist to help with common issues) for patients with IIa Anticoagulants CVD or at high risk of CV complications scheduled for NCS. When an urgent surgical intervention is required, it is I Pre-operative assessment tools—Section 4 recommended that NOAC therapy is immediately interrupted. Frailty and functional capacity In non-minor bleeding risk procedures in patients using a NOAC, it is recommended to use an interruption regimen In patients aged ≥70 years, being scheduled to undergo I IIa based on the NOAC compound, renal function, and bleeding intermediate- or high-risk NCS, frailty screening should be risk. considered using a validated screening tool. In minor bleeding risk surgery and other procedures where Adjusting risk assessments according to self-reported ability to bleeding can easily be controlled, it is recommended to I climb two flights of stairs should be considered in patients IIa perform surgery without interruption of OAC therapy. referred for intermediate- or high-risk NCS. In patients using NOACs, it is recommended that minor Transthoracic echocardiography I bleeding risk procedures are performed at trough levels TTE is recommended in patients with poor functional capacity (typically 12–24 h after last intake). and/or high NT-proBNP/BNP, or if murmurs are detected before I LMWH is recommended, as an alternative to UFH, for bridging high-risk NCS, in order to undertake risk-reduction strategies. I in patients with MHVs and high surgical risk. TTE should be considered in patients with suspected new CVD IIa For patients with mechanical prosthetic heart valves or unexplained signs or symptoms before high-risk NCS. undergoing NCS, bridging with UFH or LMWH should be TTE may be considered in patients with poor functional considered if OAC interruption is needed and patients have: (i) IIa capacity, abnormal ECG, high NT-proBNP/BNP, or ≥1 clinical IIb mechanical AVR and any thromboembolic risk factor; (ii) risk factor before intermediate-risk NCS. old-generation mechanical AVR; or (iii) mechanical mitral or To avoid delaying surgery, a FOCUS exam performed by tricuspid valve replacement. trained specialists may be considered as an alternative to TTE IIb Idarucizumab should be considered in patients on dabigatran and for pre-operative triage. requiring urgent surgical intervention with intermediate to high IIa Stress imaging bleeding risk. Stress imaging should be considered before high-risk NCS in For interventions with a very high risk of bleeding, such as spinal asymptomatic patients with poor functional capacity, and IIa or epidural anaesthesia, interruption of NOACs for up to five IIa previous PCI or CABG. half-lives and re-initiation after 24 h should be considered. Continued Continued 3836 ESC Guidelines When specific reversal agents are unavailable, PCC or activated IIa Specific diseases—Section 6 PCC should be considered for reversing NOAC effects. Coronary artery disease If an urgent surgical intervention is required, specific Pre-operative evaluation of patients with an indication for PCI coagulation tests and assessment of NOAC plasma levels IIa by an expert team (surgeon and cardiologist) should be IIa should be considered to interpret routine coagulation tests and considered before elective NCS. waning of anticoagulant effect. If bleeding risk with resumption of full-dose anticoagulation Heart failure outweighs the risk of thromboembolic events, postponing In patients with HF undergoing NCS, it is recommended to I therapeutic anticoagulation 48–72 h after the procedure may IIb regularly assess volume status and signs of organ perfusion. be considered, using post-operative thromboprophylaxis until A multidisciplinary team including VAD specialists is resumption of full OAC dose is deemed safe. recommended for peri-operative management of patients with I Bridging of OAC therapy is not recommended in patients with HF receiving mechanical circulatory support. III Downloaded from https://academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 30 July 2024 low/moderate thrombotic risk undergoing NCS. Valvular heart disease Use of reduced-dose NOAC to attenuate the risk of In patients with symptomatic severe AR or asymptomatic III post-operative bleeding is not recommended. severe AR and LVESD.50 mm or LVESDi (LVESD/BSA) Thromboprophylaxis.25 mm/m2 (in patients with small body size) or resting LVEF I It is recommended that decisions about peri-operative ≤50%, valve surgery is recommended prior to elective thromboprophylaxis in NCS are based on individual and I intermediate- or high-risk NCS. procedure-specific risk factors. In patients with moderate-to-severe rheumatic MS and If thromboprophylaxis is deemed necessary, it is symptoms or SPAP.50 mmHg, valve intervention (PMC or I recommended to choose the type and duration of surgery) is recommended before elective intermediate- or thromboprophylaxis (LMWH, NOAC, or fondaparinux) I high-risk NCS. according to type of NCS, duration of immobilization, and In asymptomatic patients with severe AS who are scheduled patient-related factors. for elective high-risk NCS, AVR (SAVR or TAVI) should be IIa In patients with a low bleeding risk, peri-operative considered after Heart Team discussion. thromboprophylaxis should be considered for a duration of up IIa In patients with symptomatic severe primary MR or to 14 or 35 days, for total knee or hip arthroplasty, respectively. asymptomatic severe primary MR with LV dysfunction (LVESD NOACs in thromboprophylaxis dose may be considered as ≥40 mm and/or LVEF ≤60%), valve intervention (surgical or IIa alternative treatments to LMWH after total knee and hip IIb transcatheter) should be considered prior to intermediate- or arthroplasty. high-risk NCS, if time allows. Patient blood management In patients with severe secondary MR who remain symptomatic despite guideline-directed medical therapy It is recommended to measure haemoglobin pre-operatively in I (including CRT if indicated), valve intervention (transcatheter IIa patients scheduled for intermediate- to high-risk NCS. or surgical) should be considered before NCS, in eligible It is recommended to treat anaemia in advance of NCS in order I patients with an acceptable procedural risk. to reduce the need for RBC transfusion during NCS. In patients with severe symptomatic AS in need of In patients undergoing surgery with expected blood loss of I time-sensitive NCS or in whom the TAVI and SAVR are ≥500 mL, use of washed cell salvage is recommended. IIb unfeasible, BAV may be considered before NCS as a bridge to It is recommended to use point-of-care diagnostics for definitive aortic valve repair. I guidance of blood component therapy, when available. Arrhythmias The use of an algorithm to diagnose and treat anaemic patients IIa In AF patients with acute or worsening haemodynamic before NCS should be considered. instability undergoing NCS, emergency electrical cardioversion I In patients undergoing NCS and experiencing major bleeding, IIa is recommended. administration of tranexamic acid should be immediately In patients with symptomatic, monomorphic, sustained VT considered. associated with myocardial scar, recurring despite optimal Use of closed-loop arterial blood sampling systems should be I IIa medical therapy, ablation of arrhythmia is recommended considered to avoid blood loss. before elective NCS. Application of meticulous haemostasis should be considered a IIa It is recommended that all patients with CIEDs that are routine procedure. reprogrammed before surgery have a re-check and necessary I A feedback/monitoring programme or clinical decision support reprogramming as soon as possible after the procedure. system should be considered to be assessed before blood IIa If indications for pacing exist according to the 2021 ESC transfusion. Guidelines on cardiac pacing and cardiac resynchronization Before allogenic blood transfusion, it should be considered IIa therapy, NCS surgery should be deferred and implantation of a to obtain an extensive consent about risks associated with IIa permanent pacemaker should be considered. transfusion. Continued Continued ESC Guidelines 3837 Ablation should be considered in symptomatic patients with Diabetes mellitus recurrent or persistent SVT, despite treatment, prior to IIa A pre-operative assessment for concomitant cardiac high-risk, non-urgent NCS. conditions is recommended in patients with diabetes with In high-risk CIED patients (e.g. with ICD or being suspected or known CAD, and those with autonomic I pacing-dependant) undergoing NCS