2022 Non-Cardiac Surgery

Essential Messages
Authors and legal information
2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac
surgery
Developed by the Task Force for cardiovascular assessment and management of patients undergoing non-car-
diac surgery of the European Society of Cardiology (ESC). Endorsed by the European Society of Anaesthesiol-
ogy and Intensive Care (ESAIC).
Chairpersons
Sigrun Halvorsen
Department of Cardiology
Oslo University Hospital Ulleval
& University of Oslo
Oslo, Norway
Email: sigrun.halvorsen@medisin.uio.no
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
Email: Julinda.mehilli@lakumed.de
Task Force Members
Salvatore Cassese (Task Force Coordinator) (Italy), Trygve S. Hall (Task Force Coordinator) (Norway),
Magdy Abdelhamid (Egypt), Emanuele Barbato (Italy/Belgium), Stefan De Hert (Belgium), Ingrid de Laval
(Sweden), Tobias Geisler (Germany), Lynne Hinterbuchner (Austria), Borja Ibanez (Spain), Radosław Lenar-
czyk (Poland), Ulrich R. Mansmann (Germany), Paul McGreavy (United Kingdom), Christian Mueller
(Switzerland), Claudio Muneretto (Italy), Alexander Niessner (Austria), Tatjana S. Potpara (Serbia), Arsen
Ristic (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 (Ger-
many), Peter Van Der Meer (Netherlands), Wojtek Wojakowski (Poland), Kai Zacharowski (Germany).
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 Associa-
tion of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA),
Heart Failure Association (HFA).
Councils: Council of Cardio-Oncology, Council on Valvular Heart Disease.
Working Groups: Adult Congenital Heart Disease, Aorta and Peripheral Vascular Diseases, Cardiovascular
Pharmacotherapy, Cardiovascular Surgery, Thrombosis.
Patient Forum
Adapted from the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing
non-cardiac surgery
European Heart Journal; 2022 - doi: 10.1093/eurheartj/ehac270
Key messages
1. The occurrence of CV complications in the peri-operative phase of NCS has a dramatic impact on
prognosis.
2. The risk of CV complications in patients undergoing NCS is determined by patient- related factors,
type of surgery or procedure, and the circumstances under which surgery takes place (local or tertiary
hospital; elective vs. emergency procedure).
3. Specific patient-related risk factors may be reduced by adequate pre-operative risk assessment and
initiation of documented risk-reduction strategies.
4. The quantification of surgical risk as low, intermediate, and high is helpful in identifying the group of
patients who should benefit the most from preventive diagnostic and therapeutic approaches to con-
comitant CV conditions.
5. Proper selection of type and timing of the surgical procedure may reduce the risk of complications.
6. It is important that patients’ values, quality of life, and preferences with respect to the benefits and
risks of surgery are taken into consideration, and that well-informed patients are involved in the deci-
sions. Risk should be communicated to the patient in absolute terms (e.g. 1 out of 100).
7. Clinical examination, patient-reported functional capacity, and non-invasive tests represent the cor-
nerstone of pre-operative cardiac assessment.
8. Instrumental and functional cardiac examination tools should be selected in view of the surgical risk,
relative diagnostic proficiency, and healthcare resource utilization and costs.
9. The peri-operative evaluation of elderly patients who require elective major NCS should include a
frailty screening, which has proved to be an excellent predictor of unfavourable health outcomes in
the older surgical population.
10. The treatment of pre-existing or newly diagnosed CV conditions, e.g. coronary and peripheral vascu-
lar disease, rhythm disorders, and HF, should be individualized according to the pre-operative risk
of NCS, and considering the recommendations of speciality guidelines.
11. A multidisciplinary approach to evaluate whether the treatment of concomitant cardiac conditions
before scheduled NCS improves the peri-operative safety without unnecessary delay is encouraged.
12. An efficient peri-operative management of antithrombotic therapies in patients scheduled
for NCS aims at offering the potential benefit of preventing thrombotic events without an excess of
bleeding complications.
13. It is important to communicate clearly and concisely to the patients, with simple written instructions,
about changes in medication in the pre- and post-operative phases.
14. The management in the peri-operative phase of NCS aims at avoiding haemodynamic imbalance
while ensuring sufficient cardioprotective action.
15. Health care providers are recommended to have high awareness for peri-operative CV complications
combined with surveillance for PMI in high-risk patients undergoing intermediate- or high-risk NCS.
16. The routine assessment of treatment quality through specific indicators is important to document and
measure the success of preventive and therapeutic strategies in patients undergoing NCS.
Gaps in evidence
 The age cut-off for individuals (considered to be cardiovascularly healthy) benefiting from risk strati-
fication work-out before NCS needs to be evaluated.
 Further studies are needed to characterize outcome differences in NCS between men and women, and
between different countries, in order to individualize peri-operative management and improve patient
safety.
 Evidence on the additive value of cardiac biomarkers, handheld ultrasound, problem FOCUS, and
stress echocardiography for cardiac risk stratification of patients scheduled for NCS presenting with
previously unknown cardiac murmur, dyspnoea, o.d.ma, and chest pain is still lacking. The impact of
FOCUS on outcomes of urgent or time-sensitive surgery needs further investigation.
 The impact of stress imaging (echocardiography or MRI) before NCS on reduction of peri-opera-
tive CV complications in non-ischaemic heart diseases needs further research.
 The role of right heart catheterization in patients with advanced HF or patients with severe pulmonary
hypertension undergoing NCS is not known.
 It is unknown whether artificial intelligence-based systems facilitate prompt detection and response to
imminent adverse events in high-risk cardiac patients undergoing high- risk NCS.
 Systematic and structured research to investigate pathophysiology, causes, and time distribution of
serious peri-operative arrhythmic events among patients undergoing NCS is still needed.
 Strategies of timing of pre-operative CIED control dependent on device type, urgency and type
of NCS, and risk of EMI during NCS need to be developed for ensuring maximal patient safety.
 Benefit of routine myocardial revascularization of high-risk CCS patients (except left main or three-
vessel CAD, reduced LV function) before elective intermediate- and high- risk NCS is not well-estab-
lished.
 More evidence regarding the need for bridging of anticoagulation in patients with MHVs is needed.
 There is a lack of evidence regarding the optimal strategies before emergent or time- sensi-
tive NCS for patients on antithrombotic treatment at high-risk for thromboembolic events, including
the: (i) use of extracorporeal haemoperfusion or NOAC antidotes (ongoing trial NCT04233073); (ii)
use of albumin, extracorporeal haemoperfusion or PB2452 specific antidote to antagonized ticagrelor
(ongoing trial NCT04286438 for PB2452); and (iii) premature cessation or bridging during interrup-
tion of oral P2Y12- receptor inhibitors (glycoprotein IIb/IIIa receptor inhibitors or cangrelor).
 There is lack of well-powered studies to evaluate the role of platelet function testing to guide the
strategy of treatment of NCS patients on antiplatelet therapy.
 Evidence regarding the need for and benefit of anticoagulation in NCS patients with post-opera-
tive AF is still lacking (ongoing ASPIRE-AF trial: NCT03968393).
 Prophylactic strategies to reduce the incidence of post-operative AF in NCS patients additional to
beta-blocker maintenance in patients already on this treatment need to be evaluated.
 The optimal cardiac work-up and therapy for patients with PMI within and outside hospital settings
need to be evaluated.
 Studies are needed to investigate the impact on post-operative outcomes of the treatment of peri-oper-
ative hypotension, the use of new HF drug classes (SGLT2 inhibitors and vericiguat), and the use of
NSAIDs as a temporary treatment of acute post-operative pain.
 Prospective studies are needed to investigate the incremental value of anaemia algorithms and blood-
sparing strategies (use of blood-sparing blood tubes) to reduce the risk of anaemia-associated adverse
outcomes among CV patients undergoing NCS.
Authors and publication
ESC Pocket Guidelines

2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac
surgery*
Developed by the task force for cardiovascular assessment and management of patients undergoing non-car-
diac surgery of the European Society of Cardiology (ESC)
Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC)
Chairpersons
Sigrun Halvorsen
Department of Cardiology,
Oslo University Hospital Ulleval, and University of Oslo,
Oslo, Norway
Julinda Mehilli
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)
Munich Heart Alliance, Munich, Germany
Task Force Members:

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 Lenar-
czyk (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 (Ger-
many), Peter Van Der Meer (Netherlands), Wojtek Wojakowski (Poland), Kai Zacharowski1 (Germany).
1Representing the European Society of Anaesthesiology and Intensive Care (ESAIC).
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 Associa-
tion of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA),
Heart Failure Association (HFA).
Councils: Council of Cardio-Oncology, Council on Valvular Heart Disease.
Working Groups: Adult Congenital Heart Disease, Aorta and Peripheral Vascular Diseases, Cardiovascular
Pharmacotherapy, Cardiovascular Surgery, Thrombosis.
Patient Forum
*Adapted from the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing
non-cardiac surgery (European Heart Journal; 2022 - doi: 10.1093/eurheartj/ehac270).

Preamble
Table of ESC Classes of recommendations and levels of evidence

Table 1 Classes of recommendations
Definition Wording to use
Class I Evidence and/or general agreement that a given treatment or Is recommended

procedure is beneficial, useful, effective. or is indicated
Class Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy
II of the given treatment or procedure.
Class Weight of evidence/opinion is in favour of usefulness/effi- Should be con-
IIa cacy. sidered
Class Usefulness/efficacy is less well established by evidence/ May be consid-
IIb opinion. ered
Class Evidence or general agreement that the given treatment or pro- Is not recom-
III cedure is not useful/ effective, and in some cases may be mended
harmful.
Table 2 Levels of evidence

Level of evi- Data derived from multiple randomized clinical trials or meta-analyses.
dence A
Level of evi- Data derived from a single randomized clinical trial or large non-ran-
dence B domized studies.
Level of evi- Consensus of opinion of the experts and/or small studies, retrospective
dence C studies, registries.
Introduction
The European Society of Cardiology (ESC) has recently completed a comprehensive review of the existing
state of medical evidence and clinical trial data relating to the management and mitigation of cardiovascular
(CV) risk in patients undergoing non-cardiac surgery. In this comprehensive review process, specific manage-
ment options were evaluated and scored according to predefined scales for rating levels of evidence and
strength of clinical care recommendations. These rating systems are detailed in inside cover page Table
1 and Table 2.
The evidence and clinical care recommendations derived from this review have been published in unabridged
form and made freely available on the ESC website and the website hosted by the European Heart Journal.
Here, we present as an educational tool a compilation of essential clinical care information extracted from the
full guidelines. Users of these Pocket Guidelines are reminded that the topics and medical evidence covered
herein are covered in considerably greater detailed in the published source documents referred to above.
Clinical risk evaluation
Introduction
CV morbidity and mortality in patients undergoing NCS are determined by two main factors: patient-related
risk and type of surgery or procedure, including the circumstances under which it takes place (experience of
institution, elective vs. emergency procedure) (Figure 1). The risk may be reduced by an adequate preoperative
patient evaluation and proper selection of type and timing of the surgical procedure.
Figure 1 Total risk is an interaction of patient-related and surgery-related risk
Ideally, the total risk should be as close as possible to the lower left corner, by choosing surgery/procedure/
anaesthesia/institution with the lowest possible risk along with efforts to mitigate the patient's CV risk.
Surgery-related risk
The surgical risk estimate is a broad approximation of 30-day risk of CV death, MI, and stroke that takes into
account only the specific surgical intervention, without considering the patient-related risk (Table 3).
Table 3 Surgical risk estimate according to type of surgery or intervention
Intermediate surgical risk (1-
Low surgical risk (<1%) High surgical risk (>5%)
5%)
Breast Carotid asymptomatic Adrenal resection
Dental (CEA or CAS) Aortic and major vascular
Endocrine: thyroid Carotid symptomatic (CEA) surgery
Eye Endovascular aortic aneurysm Carotid symptomatic (CAS)
Gynaecological: minor repair Duodenal-pancreatic surgery
Orthopaedic minor Head or neck surgery Liver resection, bile duct
(meniscectomy) Intraperitoneal: splenectomy, surgery
Reconstructive hiatal hernia repair, chole- Oesophagectomy
Superficial surgery cystectomy Open lower limb revascular-
Urological minor: (tran- Intrathoracic: non-major ization for acute limb ischa-
surethral resection of Neurological or orthopaedic: emia or amputation
the prostate) major (hip and spine sur- Pneumonectomy (VATS or
VATS minor lung re- gery) open surgery)
section Peripheral arterial angioplasty Pulmonary or liver transplant
Renal transplants Repair of perforated bowel
Urological or gynaecological: Total cystectomy
major
CAS, carotid artery stenting; CEA, carotid endarterectomy; CV, cardiovascular; MI, myocardial infarction;
VATS, video-assisted thoracic surgery.
Patient-related risk
The patient-related risk of cardiovascular (CV) complications depends on the age of the patient as well as on
the presence of CV risk factors, CV disease and other co-morbidities. Patients <65 years of age without
any CV risk factors or CV disease are considered to be at low risk, while patients with established CVD are
considered to be at high risk of CV complications.
Initial assessment
A pre-operative risk assessment is recommended, ideally at the same time as the NCS is proposed. It is recom-
mended to perform ECG and measure biomarkers (cardiac troponins and/or NT-proBNP/BNP), depending on
the patient-related as well as the surgery-related risk (Figure 2). Further, it should be considered to assess the
functional capacity. If biomarkers are elevated, and in all patients with established CVD scheduled for high-
risk surgery, a cardiology consultation is adviced (Figure 2).
Figure 2 Pre-operative assessment before non-cardiac surgery
CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram; N, no; NCS, non-cardiac surgery;
Y, yes.
aCV risk factors: hypertension, smoking, dyslipidaemia, diabetes, family history of CVD.
bBiomarkers: hs-cTn T/I (Class I) and/or BNP/NT-proBNP (Class IIa). If pathological, consult a cardiologist.
cFunctional capacity based on Duke Activity Status Index (DASI) or the ability to climb two flights of stairs.
dFor diagnostic and therapeutic efforts to be considered, see section 6 of the guidelines.
eClose follow-up after intervention and subsequent management of heart disease are advised.
For interactivity see here
Recommendations for all patients scheduled for non-cardiac surgery

Lev-
Recommendations Classa
ela
In all patients scheduled for NCS, an accurate history and clinical examina-
I C
tion are recommended.
It is recommended to perform a pre-operative risk assessment, ideally at the
I B
same time as the NCS is proposed.
If time allows, it is recommended to optimize guideline- recommended
I C
treatment of CVD and CV risk factors before NCS.
CV, cardiovascular; CVD, cardiovascular disease; NCS, non-cardiac surgery.
aClass of recommendation and level of evidence as defined in Tables 1 and 2.
Recommendations for patients <65 years without signs, symptoms, or history of cardiovas-
cular disease
Lev-
ela
In patients with a family history of genetic cardiomyopathy, it is recom-
mended to perform an ECG and TTE before NCS regardless of age and I C
symptoms.
In patients 45-65 years of age without signs, symptoms, or history
IIa C
of CVD, ECG and biomarkers should be considered before high-risk NCS.
ECG, electrocardiogram; NCS, non-cardiac surgery; TTE, transthoracic echocardiography.
Patients with murmurs, chest pain, dyspnoea, or peripheral oedema
Frequently, patients without known CVD scheduled for elective or acute NCS are referred to a cardiologist be-
cause of symptoms or signs that may be caused by CVD. Murmurs, chest pain, dyspnoea, and oedema may
suggest severe CVD, but may also be caused by non-cardiac disease. Thus, the medical history, family history,
and risk factors have to be obtained and considered. The patient's functional capacity should be assessed. The
need for further evaluation of the patient should be decided according to the risk of the planned procedure or
surgery.
Recommendations for preoperative assessment in patients with previously unknown mur-

mur, angina, dyspnoea, or peripheral oedema
Lev-
ela
Newly detected murmur
In patients with a newly detected murmur and symptoms or signs
I C
of CVD, TTE is recommended before NCS.
In patients with a newly detected murmur suggesting clinically significant
I C
pathology, TTE is recommended before high-risk NCS.
In patients with a newly detected murmur, but without other signs or symp-
toms of CVD, TTE should be considered before moderate and high- IIa C
risk NCS.
Previously unknown angina
If a patient scheduled for elective NCS has chest pain or other symptoms
suggestive of undetected CAD, further diagnostic workup before NCS is rec- I C
ommended.
If a patient in need of acute NCS also has chest pain or other symptoms sug-
gestive of undetected CAD, a multidisciplinary assessment approach is rec- I C
ommended to choose the treatment with lowest total risk for the patient.
Dyspnoea and/or peripheral oedema
In patients with dyspnoea and/or peripheral oedema, an ECG and an NT-
proBNP/BNP test is indicated before NCS, unless there is a certain non-car- I C
diac explanation.
In patients with dyspnoea and/or peripheral oedema and elevated NT-proB-
I C
NP/BNP, TTE is recommended before NCSb.
BNP, B-type natriuretic peptide; CAD, coronary artery disease; CVD, cardiovascular disease; ECG,
electrocardiogram; NSC, non-cardiac surgery; NT-proBNP, N-terminal pro-B-type natriuretic peptide; TTE,
transthoracic echocardiography.
bIf BNP/NT-proBNP testing is not available, TTE should be considered.

The patient perspective
Patients with established CVD may face concerns about their underlying disease and current CV medication,
about co-ordination between the surgical team and their cardiologist, and about the potential excessive risk
compared with the expected outcome of the surgery. Time should be allowed to address concerns and to pro-
vide evidence-based information on the risk/benefit trade-offs and the surgical treatment options (including
non-surgical or ‘do nothing' alternatives) to ensure informed consent, and to allow patients to engage in shared
decision-making with the aim of supporting the best decision
Recommendations for patient information

Lev-
ela
It is recommended to give patients individualized instructions for pre-opera-
tive and post-operative changes in medication, in verbal and written formats I C
with clear and concise directions.
It should be considered to set up a structured information list (e.g. check list
to help with common issues) for patients with CVD or at high risk IIa C
of CV complications scheduled for NCS.
Pre-operative assessment tools
Risk scores
Several risk indices have been developed based on multivariable analyses of observational data and have been
validated during the last decade. Most risk calculators integrate both patient-related and surgery-related risk
factors, but none of them include biomarkers among their variables. See section 4.1.1 in the full ESC guide-
line. The risk calculators can be used in addition, or as an alternative, to the assessment of surgery-related and
patient-related risk factors described in section 2. The Task Force decided against recommending one specific
risk score. The Task Force also decided that the selection criteria for further pre-operative testing should be
clinical criteria, and not based on a specific score.
Frailty and functional capacity
Recommendations for pre-operative assessment of frailty and functional capacity

Lev-
ela
In patients ≥70 years old, being scheduled to undergo intermediate- or high-
risk NCS, frailty screening should be considered using a validated screening IIa B
tool.
Adjusting risk assessments according to self-reported ability to climb two
flights of stairs should be considered in patients referred for intermediate- or IIa B
high-risk NCS.
NCS, non-cardiac surgery.
Electrocardiography
The 12-lead ECG is a widely available, simple, inexpensive tool that is able to semi-quantitatively assess car-
diac risk (e.g. Q waves indicative of prior MI), and detect unknown CV conditions requiring therapy, e.g. atrial
fibrillation (AF) or AV-block. It is not recommended to routinely obtain a pre-operative ECG in low-risk pa-
tients undergoing low-risk NCS.
Recommendation for pre-operative electrocardiography

Lev-
Recommendation Classa
ela
In patients who have known CVD or CV risk factors (including age ≥65
years), or symptoms or signs suggestive of CVD, it is recommended to ob- I C
tain a pre-operative 12-lead ECG before intermediate and high-risk NCS.
Biomarkers
Widely available and simple biomarkers that detect and quantify essential prognostic aspects of cardiac in-
volvement may aid in the evaluation of risk for CV complications (Figure 2 and Figure 3). Hs-cTn T/I quanti-
fies myocardial injury, and BNP and NT-proBNP quantify haemodynamic cardiac wall stress. Hs-cTn T/I
and BNP/NT-proBNP complement both clinical assessment and the ECG in pre-operative risk prediction. Sev-
eral large prospective studies have shown that both hs-cTn T/I and BNP/NT-proBNP have high and incremen-
tal prognostic value for peri-operative cardiac complications. Furthermore, measurements of hs-cTn T/I before,
as well as serially after surgery (e.g. 24 and 48 h post-operatively) are needed for reliably and rapidly detection
of peri-operative myocardial infarction/injury (Figure 3 and Figure 13).
Figure 3 Recommended measurements to assess and detect the risk of post-operative cardiac complications
ECG, electrocardiogram; hs-cTn, high-sensitivity cardiac troponin; PMI, peri-operative myocardial infarction/
injury; ULN, upper limit of normal.
In patients scheduled to undergo intermediate- or high-risk surgery, pre-operative risk assessment is comple-
mented by ECG, hs-cTn and BNP/NT-proBNP. An absolute increase in hs-cTn concentration of more than
the ULN on Day 1 or 2 after surgery compared to the pre-operative level is defined as PMI. In the absence of a
pre-operative hs-cTn T/I concentration, a very high hs-cTn T/I concentration on Day 1 (e.g. >5-times the
ULN) or a relevant change from Day 1 to Day 2 (absolute increase or decrease more than the ULN vs. Day 1)
would also allow the reliable diagnosis of PMI. Detection of PMI should trigger ECG recording and detailed
clinical evaluation for PMI work-up and therapy. The differential diagnosis of PMI according to the fourth uni-
versal definition of MI is discussed in section 8 of the guidelines. The ESC 0/1/2 h algorithm has not been vali-
dated for the peri-operative setting and cannot be used here.
Recommendations for pre-operative risk assessment - biomarkers

Lev-
ela
In patients who have known CVD, CV risk factors (including age ≥65
years), or symptoms suggestive of CVD, it is recommended to measure hs-
I B
cTn T or hs-cTn I before intermediate- and high-risk NCS, and at 24 hours
and 48 hours after.
In patients who have known CVD, CVD risk factors (including age ≥65
years), or symptoms suggestive of CVD, it should be considered to mea- IIa B
sure BNP or NT-proBNP before intermediate- and high-risk NCS.
In low-risk patients undergoing low- and intermediate-risk NCS, it is not
recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/ III B
NT-proBNP concentrations.
BNP, B-type natriuretic peptide; CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram;
hs-cTn I, high-sensitivity cardiac troponin; hs-cTn T, high-sensitivity cardiac troponin T; NCS, non-cardiac
surgery; NT-proBNP, N-terminal proBNP.
Abnormal ECG: pathological Q wave, ST-T wave changes, non-sinus rhythm, left bundle branch block. Ab-
normal pre-operative hs-cTnT/I: more than ULN. Age, sex, and known cardiac disease should also be consid-
ered when interpreting the pre-operative concentration.
Abnormal BNP: ≥35 pg/mL; abnormal NT-proBNP: ≥125 pg/mL. BNP/NT-proBNP should be interpreted as
quantitative markers of heart failure, and also take into account age, sex, obesity, and known cardiac disease.
Please note that age, renal dysfunction, and obesity are important confounders in the age group in which we
recommend measurement of BNP/NT-proBNP, while sex has less impact.
Transthoracic echocardiography
In large retrospective cohorts, routine pre-operative TTE before high-risk NCS did not reduce the risk of post-
operative MACE and did not provide more information than clinical risk models. Poor functional capacity, ab-
normal ECG, suspected new or significant CVDs, unexplained dyspnoea, or coexisting clinical risk factors are
appropriate indications for TTE.
Recommendations for transthoracic echocardiography
Lev-
ela
TTE is recommended in patients with poor functional capacityb and
high NT-proBNP/BNP,c or if murmurs are detected before high-risk NCS, to I B
undertake risk reduction strategies.
TTE should be considered in patients with suspected new CVD or unex-
IIa B
plained signs or symptoms, before high-risk NCS.
TTE may be considered in patients with poor functional capacity, abnor-
mal ECG, high NT-proBNP/BNP,c or ≥1 clinical risk factor, before interme- IIb B
diate-risk NCS.
To avoid delaying surgery, a FOCUS exam performed by trained specialists
IIb B
may be considered as an alternative to TTE for pre-operative triage.
Routine pre-operative evaluation of LV function is not recommended. III C
BNP, B-type natriuretic peptide; CVD, cardiovascular disease; FOCUS, focused cardiac ultrasound; LV, left
ventricular; RCRI, Revised Cardiac Risk Index; NCS, non-cardiac surgery; NT-proBNP, N-terminal pro-B-
type natriuretic peptide; TTE, transthoracic echocardiography.
bSee section 4.2 of the guidelines.
c≥125 pg/mL/35 pg/mL.

Stress imaging
The use of stress imaging is appropriate for risk assessment in patients with clinical risk factors and poor func-
tional capacity. The choice of the test is driven by local expertise. Selection and safe performance of stress
imaging should comply with related guidelines and recommendations.
Recommendations for stress imaging
Lev-
ela
Stress imaging is recommended before high-risk elective NCS in patients
with poor functional capacityb and high likelihood of CADc or high clinical I B
risk.d
Stress imaging should be considered before high-risk NCS in asymptomatic
IIa B
patients with poor functional capacityc and prior PCI or CABG.
Stress imaging may be considered before intermediate-risk NCS when is-
chaemia is of concern in patients with clinical risk factors and poor function- IIb B
al capacityc.
Stress imaging is not recommended routinely before NCS. III C
CABG, coronary artery bypass graft; CAD, coronary artery disease; NCS, non-cardiac surgery; PCI, percuta-
neous coronary intervention.
bPhysical capacity based on Duke Activity Status Index (DASI) or inability to climb 2 flights of stairs.
cPre-test probability >15% based on age, sex, and nature of symptoms, or ≥2 risk factors for CVD (dyslipi-
daemia, diabetes, hypertension, smoking, family history of CVD) or resting ECG changes (Q-wave or ST-seg-
ment/ T-wave changes), or LV dysfunction suggestive of CAD.
d≥1 clinical risk factor according to the Revised Cardiac Risk Index (ischemic heart disease, cerebrovascular
disease, history of congestive heart failure, serum creatinine level >2 mg/dL, diabetes requiring insulin thera-
py).
Angiography
Coronary computed tomography angiography (CCTA) is recommended as an initial test for diagnos-
ing CAD in stable patients with a low clinical likelihood or no previous diagnosis of CAD, and characteristics
associated with a high likelihood of good image quality.
There is a lack of information from RCTs relating to the usefulness of invasive coronary angiography (ICA) in
patients scheduled for NCS. Also, ICA assessment may cause an unnecessary and unpredictable delay in an
already planned surgical intervention, as well as adding an independent procedural risk to the overall risk. De-
spite the fact that CAD may be present in a significant number of patients requiring NCS, indications for pre-
operative coronary angiography and revascularization are similar to angiography indications in the non-surgi-
cal setting.
Recommendations for coronary angiography
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It is recommended to use the same indications for ICA and revascularization
I C
pre-operatively as in the non-surgical setting.
CCTA should be considered to rule out CAD in patients with suspect-
ed CCS or biomarker-negative NSTE-ACS in case of low-to-intermediate
IIa C
clinical likelihood of CAD, or in patients not suitable for non-invasive func-
tional testing undergoing non-urgent, intermediate, and high risk NCS.
Pre-operative ICA may be considered in stable CCS patients undergoing
IIb B
elective surgical CEA.
Routine pre-operative ICA is not recommended in stable CCS patients un-
III C
dergoing low and intermediate risk NCS.
CAD, coronary artery disease; CCS, chronic coronary syndrome; CCTA, coronary computed tomography
angiography; CEA: carotid endarterectomy; ICA, invasive coronary angiography; NCS, non-cardiac surgery;
NSTE-ACS, non-ST-segment elevation acute coronary syndrome.
General risk-reduction strategies
CV risk factors and lifestyle interventions
Control of CV risk factors, including blood pressure, dyslipidaemia, and diabetes, is important before NCS. Of
the lifestyle changes recommended before surgery, smoking cessation is the best documented.
Recommendations for lifestyle and cardiovascular risk factors
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Smoking cessation more than 4 weeks before NCS is recommended to re-
I B
duce post-operative complications and mortality.
Control of CV risk factors, including blood pressure, dyslipidemia, and dia-
I B
betes, is recommended before NCS.
CV, cardiovascular; NCS, non-cardiac surgery.
Pharmacological
Recommendations for pharmacological treatment

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Initiation
In patients with an indication for statins, it should be considered to initiate
IIa C
statins peri-operatively.
Pre-operative initiation of beta-blockers in advanceb of high- risk NCS may
be considered in patients who have ≥2 clinical risk factors,c in order to re- IIb A
duce the incidence of peri-operative myocardial infarction.
Pre-operative initiation of beta-blocker in advance of NCS may be consid-
IIb B
ered in patients who have known CAD or myocardial ischaemia.d
Routine initiation of beta-blocker peri-operatively is not recommended. III A
Continuation
Peri-operative continuation of beta-blockers is recommended in patients cur-
I B
rently receiving this medication.
In patients already on statins, it is recommended to continue statins during
I B
the peri-operative period.
In patients with stable HF, peri-operative continuation of RAAS inhibitors
IIb C
may be considered.
Interruption
In patients without HF, withholding RAAS inhibitors on the day
IIa B
of NCS should be considered to prevent peri-operative hypotension.
For patients on diuretics to treat hypertension, transient discontinuation of
IIa B
diuretics on day of NCS should be considered.
It should be considered to interrupt SGLT-2 inhibitor therapy for at least 3
IIa C
days before intermediate and high-risk NCS.
b.p.m., beats per minute; CAD, coronary artery disease; HF, heart failure; NCS, non-cardiac surgery; RAAS,
renin-angiotensin-aldosterone system; RCRI, Revised Cardiac Risk Index; SGLT-2, sodium-glucose co-trans-
porter-2.
bIdeally at least 1 week before surgery, starting with a low dose with dose titration for target heart rate. The tar-
get is a resting heart rate 60-70 b.p.m., with a systolic BP >100 mmHg.
cIschaemic heart disease, cerebrovascular disease, renal insufficiency, or diabetes mellitus, according to
the RCRI score.

dTreatment should ideally be initiated between 30 days and (at least) 2 days before surgery, starting at a low
dose, and should be continued post-operatively.

Peri-operative handling of antithrombotic agents
Management of patients taking antithrombotic agents and needing surgery should consider the patient- and
surgery-related risk of bleeding and thrombosis. Furthermore, the pharmacokinetic and pharmacodynamic
characteristics of the antithrombotic drugs in use must be considered (Table 4 and Table 5). The risk of bleed-
ing associated with different types of surgery is shown in Table 6.
Table 4 Pharmacokinetic and pharmacodynamic characteristics of antiplatelets
ASA, acetylsalicylic acid; b.i.d., twice a day; Cmax, maximum serum concentration; i.v., intravenous; LD, load-
ing dose; NR, non-relevant; o.d., once daily.
aTime to C
max for may be delayed by 8 h or more following a dose of opiate.
bDepending on response status.
Table 5 Pharmacokinetic and pharmacodynamic characteristics of oral anticoagulants
b.i.d., twice a day; Cmax, maximum serum concentration; FIIa, factor IIa; FXa, factor Xa; INR, International
normalized ratio; LD, loading dose; NOAC, non-vitamin K antagonist oral anticoagulant; o.d., once daily;
VKORC1, vitamin K epoxide reductase complex 1.
Table 6 Bleeding risk according to type of non-cardiac surgery
Surgery with low
Surgery with high bleeding
bleeding risk (infre-
Surgery with minor bleeding risk risk (frequent or with signifi-
quent or with low
cant clinical impact)
clinical impact)
Cataract or glaucoma procedure Abdominal surgery: Abdominal surgery with liver
Dental procedures: extractions (1- cholecystectomy, biopsy, extracorporeal
3 teeth), periodontal surgery, hernia repair, shockwave lithotripsy
implant positioning, endodontic colon resection Extensive cancer surgery
(root canal) procedures, subgin- Breast surgery (e.g. pancreas, liver)
gival scaling/ cleaning Complex dental pro- Neuraxial (spinal or epidural)
Endoscopy without biopsy or re- cedures (multiple anaesthesia
section tooth extractions) Neurosurgery (intracranial,
Superficial surgery (e.g. abscess Endoscopy with sim- spinal)
incision, small skin excisions/ ple biopsy Major orthopaedic surgery
biopsy) Gastroscopy or Procedures with vascular or-
colonoscopy with gan biopsy (kidney or pro-
simple biopsy state)
Large-bore needles Reconstructive plastic
procedures, e.g. surgery
bone marrow or Specific interventions (colon
lymph node biopsy polypectomy, lumbar
Non-cataract oph- puncture, endovascular
thalmic surgery aneurysm repair)
Small orthopaedic Thoracic surgery, lung resec-
surgery (foot, hand tion surgery
arthroscopy) Urological surgery (prostate-
ctomy, bladder tumour re-
section)
Vascular surgery
(e.g. AAA repair, vascular
bypass)
AAA, abdominal aortic aneurysm.
Antiplatelets
The management of antiplatelet therapy in patients who have undergone recent PCI and are scheduled
for NCS should balance the risk of life-threatening surgical bleeding on antiplatelet therapy against the risk of
life-threatening stent thrombosis due to premature DAPT discontinuation. See Figure 4 and Figure 5 for our
recommendations.
Figure 4 Recommendations for management of antiplatelet therapy in patients undergoing non-cardiac surgery
ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; GPI, glycoprotein IIb/IIIa inhibitors; N, no;
NCS, non-cardiac surgery; PCI, percutaneous coronary intervention; Y, yes.
aHigh risk for peri-operative stent thrombosis defined by at least one of the following: history of stent thrombo-
sis under antiplatelet therapy, reduced left ventricular ejection fraction (<40%), poorly controlled diabetes, se-
verely impaired renal function/haemodialysis, recent complex PCI (i.e. severely calcified lesion, left main PCI,
chronic total occlusion, bifurcational/crush technique, bypass graft PCI), or stent malapposition/ residual dis-
section.
bTiming of resumption after interdisciplinary risk assessment as soon as possible (within 48 h) after surgery.
cFor dosing, please see Figure 6.

Figure 5 P2Y12 inhibitor interruption after percutaneous coronary intervention before elective non-cardiac
surgery
MI, myocardial infarction; N, no; PCI, percutaneous coronary intervention; Y, yes.

aAvailability of 24h cath-lab service is suggested in case of major surgery within 6 months in non-ACS/non-
high-risk patients and within 12 months in ACS/high-risk patients

bHigh risk for peri-operative stent thrombosis defined by at least one of the following: history of recurrent MI,
history of stent thrombosis under antiplatelet therapy, reduced left ventricular ejection fraction (<40%), poorly
controlled diabetes, severely impaired renal function/haemodialysis, recent complex PCI (i.e. severely calcified
lesion, left main PCI, chronic total occlusion, bifurcational/crush technique, bypass graft PCI), stent malappo-
sition/residual dissection.
cClass III LoE C.
dClass IIa LoE B.
eClass I LoE A.
fClass III LoE B.
gClass IIb LoE B.
hClass IIa LoE B.
dClass I LoE A.
Although generally not recommended, bridging with i.v. compounds (eptifibatide/ tirofiban or cangrelor)
might be applicable in rare cases when DAPT cannot be interrupted before NCS (see Figure 5 and Figure 6).
Figure 6 Bridging with intravenous antiplatelet agents
ASA, acetylsalicylic acid; FU, follow-up; LD, loading dose; NCS, non-cardiac surgery; o.d., once daily.
aTirofiban: 0.1 µg/kg/min; if creatinine clearance <50 mL/min, adjust to 0.05 µg/kg/min. Eptifibatide: 2.0 µ/
kg/min; if creatinine clearance is <50 mL/min, adjust to 1.0 µg/kg/min.

bUntil oral P2Y inhibitor therapy is possible.
12
cInitiate within 72 h from P2Y inhibitor discontinuation at a dose of 0.75 μg/kg/min for a minimum of 48 h
12
and a maximum of 7 days.

Recommendations for the use of antiplatelet therapy in patients undergoing non-cardiac
surgery
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Initiation
It is recommended to delay elective NCS until 6 months after elec-
I A
tive PCI and 12 months after ACS, respectively.
After elective PCI, it is recommended to delay time-sensitive NCS until a
I B
minimum of 1 month of DAPT treatment has been given.
In patients with a recent PCI scheduled for NCS, it is recommended that
management of antiplatelet therapy is discussed between the surgeon, the I C
anaesthesiologist and the cardiologist.
In high-risk patients with a recent PCI (e.g. STEMI patients or high
risk NSTE-ACS patients), a DAPT duration of at least 3 months should be IIa C
considered before time-sensitive NCS.
Continuation of medication
In patients with a prior PCI, it is recommended to continue aspirin peri-oper-
I B
atively if the bleeding risk allows.
Recommended time interval for drug interruption before NCS
If interruption of P2Y12 inhibitor is indicated, it is recommended to with-
hold ticagrelor for 3-5 days, clopidogrel for 5 days, and prasugrel for 7 days I B
prior to NCS.
For patients undergoing high bleeding risk surgery (e.g. intracranial, spinal
neurosurgery or vitroretinal eye surgery), it is recommended to interrupt as- I C
pirin for at least 7 days pre-operatively.
In patients without a history of PCI, interruption of aspirin at least 3 days be-
fore NCS may be considered if the bleeding risk outweighs the ischaemic IIb B
risk, to reduce the risk of bleeding.
Resumption of medication
If antiplatelet therapy has been interrupted before a surgical procedure, it is
recommended to restart therapy as soon as possible (within 48 h) post- I C
surgery, according to interdisciplinary risk assessment.
ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; NCS, non-cardiac surgery; NSTE-ACS, non-
ST-segment elevation acute coronary syndrome; PCI, percutaneous coronary intervention; STEMI, ST-eleva-
tion myocardial infarction.
Oral anticoagulants
Peri-operative management of OAC therapy depends on surgery- and patient-related factors and the specif-
ic OAC agent in use [vitamin K antagonist (VKA) or a non- VKA oral anticoagulant (NOAC)]. See Figure
7 for a summary of recommendations for the management of OACs in patients undergoing NCS. Surgery-re-
lated factors include urgency of the intervention and the surgery-related bleeding risk (reflecting both the risk
of bleeding occurrence and the risk of adverse outcome if bleeding occurs) (see Table 6). Procedures where
mechanical compression is not feasible carry a high risk of serious bleeding complications.
In patients treated with NOACs undergoing NCS, temporary discontinuation of NOAC therapy may be re-
quired, while many less-invasive procedures with a relatively low risk of bleeding may be performed under
minimally interrupted or uninterrupted NOAC therapy (Figure 8 and Figure 9). The time-based NOAC inter-
ruption (Figure 8 and Figure 9) appears safe in most patients undergoing surgery. When an urgent surgical in-
tervention is required, it is recommended that NOAC therapy is immediately interrupted.
Figure 7 Recommendations for management of oral anticoagulation therapy in patients undergoing non-cardiac
surgery
CHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular dis-
ease, age 65-74 years, sex category (female); N; no; NCS, non-cardiac surgery; NOAC, non-vitamin K antago-
nist oral anticoagulant; VKA, vitamin K antagonist; VTE, venous thromboembolism; Y, yes.
aMechanical aortic valve replacement and any thromboembolic risk factor (atrial fibrillation, previous throm-
boembolism, severe left ventricular dysfunction, hypercoagulable state), or older-generation mechanical AVR,
or a mechanical mitral valve replacement.
bRecent stroke <3 months, high risk of VTE recurrences (e.g. antithrombin 3 deficiency or protein C and/or S
deficiency), left ventricular apex thrombus, AF with a very high stroke risk.
cBridging with unfractionated heparin or low molecular weight heparin.
de.g. >3 months after stroke/VTE.
eFor NOAC management during NCS, see Figure 8 and Figure 9.

Figure 8 Peri-operative management of non-vitamin K antagonist oral anticoagulant according to the peripro-
cedural risk of bleeding
NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral anticoagulant.

aIn patients/circumstances favouring NOAC accumulation (e.g. renal dysfunction, older age, concomitant med-
ication), the NOAC should be paused 12-24 h earlier.

bIn patients on rivaroxaban or edoxaban taking the dose in the evening, the evening dose may be skipped.
cNOACs have predictable weaning of the anticoagulant effect. Owing to the increase in bleeding risk associat-
ed with bridging, it is generally not recommended to use bridging in patients taking NOACs.
Figure 9 Timing of last NOAC dose before elective NCS according to renal function
-
GFR, glomerular filtration rate; LMWH, low molecular weight heparin; NCS, non-cardiac surgery; NOAC,
non-vitamin K antagonist oral anticoagulant; UFH, unfractionated heparin.
/Recommendations for interruption and resumption of anticoagulants in patients undergoing
non-cardiac surgery
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Interruption of anticoagulation
When an urgent surgical intervention is required, it is recommended
I C
that NOAC therapy is immediately interrupted.
Idarucizumab should be considered in patients on dabigatran requiring ur-
gent surgical intervention with intermediate to high bleeding risk or risk of IIa B
bleeding with significant clinical impact.
In non-minor bleeding risk procedures in patients using a NOAC, it is rec-
ommended to use an interruption regimen based on the NOAC compound, I B
renal function, and bleeding risk.
For interventions with a very high risk of bleeding, such as spinal or epidural
anaesthesia, interruption of NOACs for up to five half-lives and re-initiation IIa C
after 24 h should be considered.
When specific reversal agents are not available, PCC or activat-
IIa C
ed PCC should be considered for reversing NOAC effects.
If an urgent surgical intervention is required, specific coagulation tests and
assessment of NOAC plasma levels should be considered to interpret routine IIa C
coagulation tests and waning of anticoagulant effect.
Continuation of medication
In minor surgery and other procedures where bleeding can be easily con-
trolled, it is recommended to perform surgery without interruption I B
of OAC therapy.
LMWH is recommended, as an alternative to UFH, for bridging in patients
I B
with MHVs and high surgical risk.
In patients using a NOAC, it is recommended that minor bleeding risk proce-
I C
dures are performed at trough levels (typically 12-24 h after last intake).
For patients with mechanical prosthetic heart valves undergoing NCS, bridg-
ing with UFH or LMWH should be considered if OAC interruption is needed
and patients have: (i) mechanical AVR and any thromboembolic risk factor; IIa C
(ii) old-generation mechanical AVR; and (iii) mechanical mitral or tricuspi-
dal valve replacement.
Bridging of OAC therapy is not recommended in patients with low/ moder-
III B
ate thrombotic risk undergoing NCS.
Start/resumption of medication
If bleeding risk with resumption of full-dose anticoagulation outweighs the
IIb C
risk of thromboembolic events, postponing therapeutic anticoagulation 48-72
h after the procedure may be considered, using post-operative thrombopro-
phylaxis until resumption of full OAC dose is deemed safe.
Use of reduced-dose NOAC to attenuate the risk of post-operative bleeding
III C
is not recommended.
AVR, aortic valve replacement; OAC, oral anticoagulant; LMWH, low molecular weight heparin; MHV, me-
chanical heart valve; NCS, non-cardiac surgery; NOAC, non-vitamin K oral anticoagulant; PCC, prothrombin
complex concentrate; UFH, unfractionated heparin.
aClass of recommendation and level of evidence as defined in Tables 1 and 2./
Thromboprophylaxis
Trends show that the case-fatality of peri-operative VTE has declined over the past decades. Its causal relation-
ship with preventable mortality has been challenged by a recent meta-analysis. Thus, peri-opera-
tive VTE should be regarded as a marker of increased mortality risk rather than a causal factor. Careful pre-
operative assessment is essential to identify patients with increased VTE risk who might benefit from peri-op-
erative thromboprophylaxis. Procedure-related (e.g. type of surgery and likelihood of post-operative immobi-
lization) and patient-related factors contribute to the risk of VTE. For non-orthopaedic surgical patients at low
risk for VTE, mechanical methods of VTE prophylaxis (graduated compression stockings, intermittent pneu-
matic compression, or venous foot pump) rather than pharmacologic prophylaxis or no prophylaxis are recom-
mended. Patients with CV disease (e.g. patients with recent MI or HF) have increased risk for peri-opera-
tive VTE.
Recommendations on thromboprophylaxis
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It is recommended that decisions about peri-operative thromboprophylaxis
I A
in NCS are based on individual and procedure- specific risk factors.
If thromboprophylaxis is deemed necessary, it is recommended to choose the
type and duration of thromboprophylaxis (LMWH, NOAC, or fondaparinux)
I A
according to type of NCS, duration of immobilization and patient-related
factors.
In patients with a low bleeding risk, peri-operative thromboprophylaxis
should be considered for a duration of up to 14 or 35 days, for total knee or IIa A
hip arthroplasty, respectively.
NOACs in thromboprophylaxis dose may be considered as alternative treat-
IIb A
ments to LMWH after total knee and hip arthroplasty.
LMWH, low molecular weight heparin; NCS, non-cardiac surgery; NOAC, non-vitamin K oral anticoagulant.
Patient blood management
Pre-operative anaemia—diagnosis and treatment

Major surgery is associated with a high risk of peri-operative blood loss. Preferred treatment of acute anaemia
related to peri-operative blood loss is transfusion of allogenic blood products. A large body of evidence, how-
ever, indicates that inappropriate transfusion of red blood cells (RBC) may be associated with inherent compli-
cations and impaired surgical outcome. Therefore, it is important to identify and treat anaemia pre-operatively
in any patients undergoing major surgery.
Iron deficiency (ID) is the underlying cause of anaemia in approximately 50% of all cases. Serum ferritin level
<30 ng/mL, transferrin saturation <20%, and/or microcytic hypochromic red cells (mean corpuscular volume
<80 fl, mean corpuscular haemoglobin <27 g/dL) are indicative of ID (Table 7).
Table 7 Laboratory parameters for the diagnosis of absolute iron-deficiency anaemia
Parameter Normal Iron deficiency
Mean corpuscular haemoglobin (g/dL) 28-33 <27
Mean cellular volume (fL) 80-96 <80
Transferrin saturation (%) 16-45 <20
Ferritin (ng/mL) 18-360 <30a
Reticulocytes haemoglobin (ng/mL) 18-360 <30
aIn cases of chronic kidney disease, chronic heart failure or infections, iron deficiency is diagnosed with ferritin
level <100 ng/mL or transferrin saturation <20%.
Recommendations for intra- and post-operative complications associated with anaemia

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It is recommended to measure haemoglobin pre-operatively, in patients
I B
scheduled for intermediate- to high risk NCS.
It is recommended to treat anaemia in advance of NCS in order to reduce
I A
the need for RBC transfusion during NCS.
The use of an algorithm to diagnose and treat anaemic patients be-
IIa C
fore NCS should be considered.
NCS, non-cardiac surgery; RBC, red blood cell.
Reduction of iatrogenic diagnostic/surgery-related blood loss
Reduction of surgery-related blood loss starts from the pre-operative stage with appropriate cessation strategies
for anticoagulation and antiplatelet therapy. Blood- loss-avoiding intra-operative approaches include: (i) ad-
vanced anaesthetic; (ii) advanced surgical techniques with meticulous haemostasis, such as minimally invasive
surgery and laparoscopic surgery; (iii) judicious use of diathermy dissection; (iv) physician's mindfulness re-
garding limiting blood loss; and (v) application of topical haemostatic agents. The Patient Blood Management
approach is a patient-centred and multidisciplinary approach to manage anaemia, minimize iatrogenic blood
loss and bleeding, and harness tolerance to anaemia in an effort to improve patient outcomes.
Recommendations for intra- and post-operative complications associated with blood loss
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In patients undergoing surgery with expected blood loss of ≥500 mL, use of
I A
washed cell salvage is recommended.
It is recommended to use point-of-care diagnostics for guidance of blood
I A
component therapy, when available.
In patients undergoing NCS and experiencing major bleeding, administra-
IIa A
tion of tranexamic should be considered immediately.
Use of closed-loop arterial blood sampling systems should be considered to
IIa B
avoid blood loss.
Application of meticulous haemostasis should be considered a routine pro-
IIa B
cedure.
NCS, non-cardiac surgery.
Specific diseases
Introduction
Patients with CVD have an increased risk of peri-operative CV complications. Both the risk of complications
and the peri-operative management depend on the specific type of CVD.
Coronary artery diseases
The peri-operative risk of CV complications for patients with established CAD depends on the base-
line CV risk, the type of surgery, and the degree of urgency of the NCS. Older patients have a higher risk than
younger patients, and patients with a recent ACS have a higher risk than patients with CCS. Also, the presence
of comorbidities may influence the risk. Figure 10 shows a summary of diagnostic and therapeutic pathways in
patients with CAD scheduled for NCS.
Figure 10 Management of patients with acute or chronic coronary syndrome scheduled for non-cardiac surgery
ACS, acute coronary syndrome; BNP, B-type natriuretic peptide; CABG, Coronary artery bypass graft; CAD,
coronary artery disease; CCS, chronic coronary syndrome; ECG, electrocardiogram; FFR, fractional flow
reserve; hs-cTn, High-sensitivity cardiac troponin; ICA, invasive coronary angiography; iwFR, instantaneous
wave-free ratio; N; no; NCS, non-cardiac surgery; NT-proBNP, N-terminal proBNP; PCI, percutaneous coro-
nary intervention; TTE, transthoracic echocardiography; Y, yes.
aBiomarkers: hs-cTn T/I (Class I) ± BNP/NT-proBNP (Class IIa).
bFunctional capacity based on Duke Activity Status Index (DASI) or the ability to climb two flights of stairs.
cICA ± PCI/CABG on a case-by-case basis according to the Heart Team.

Recommendations on the timing of non-cardiac surgery and revascularization in patients
with known coronary artery disease
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ela
Patients with CCS
If PCI is indicated before NCS, the use of new generation DES is recom-
I A
mended over BMS and balloon angioplasty.
Pre-operative evaluation of patients with an indication for PCI by an expert
IIa C
team (surgeon and cardiologist) should be considered before elective NCS.
Myocardial revascularization before high-risk elective NCS may be consid-
ered, depending on the amount of ischaemic myocardium, refractory symp-
IIb B
toms, and findings at coronary angiography (as in the case of left main dis-
ease).
Routine myocardial revascularization before low- and intermediate-
III B
risk NCS in patients with CCS is not recommended.
Patients with ACS
If NCS can safely be postponed (e.g. at least 3 months), it is recommended
that patients with ACS being scheduled for NCS undergo diagnostic and I A
therapeutic interventions as recommended for ACS patients in general.
In the unlikely combination of a life-threatening clinical condition requiring
urgent NCS, and NSTE-ACS with an indication for revascularization, the
IIa C
priorities for surgery on a case-by-case basis should be considered by the ex-
pert team.
ACS, acute coronary syndrome; BMS, bare metal stent; CAD, coronary artery disease; CCS, chronic coronary
syndrome; DES, drug-eluting stent; NCS, non-cardiac surgery; NSTE-ACS, non-ST segment elevation acute
coronary syndrome; PCI, percutaneous coronary interventions.
Chronic heart failure
Heart failure (HF) is an established risk factor for post-operative mortality. In order to reduce the risk of acute
decompensation as well as the risk of mortality, optimal guideline-directed medical treatment of HF before
scheduled NCS is recommended. Special attention should be given to the fluid balance, since high-volume in-
fusion is often needed in the peri-operative period.
Recommendations for management of heart failure in patients undergoing non-cardiac
surgery
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ela
In patients with suspected or known HF scheduled for high- risk NCS, it is
recommended to evaluate LV function with echocardiography and measure- I B
ment of NT-proBNP/BNP levels, unless this has recently been performed.
It is recommended that patients with HF undergoing NCS receive optimal
I A
medical treatment according to current ESC Guidelines.
In patients with HF undergoing NCS, it is recommended to regularly assess
I C
volume status and signs of organ perfusion.
A multidisciplinary team including VAD specialists is recommended for
I C
peri-operative management of patients with HF receiving MCS.
BNP, B-type natriuretic peptide; ESC, European Society of Cardiology; HF, heart failure; LV, left ventricular;
MCS, mechanical circulatory support; NCS, non-cardiac surgery; NT-proBNP, N-terminal pro-B-type natri-
uretic peptide. VAD, ventricular assist device.
Valvular heart disease
Valvular heart disease (VHD) increases the risk of peri-operative CV complications during NCS. The magni-
tude of risk is highly variable and depends on the severity of VHD and the type of NCS. It is particularly in-
creased in patients with obstructive valve pathology—symptomatic AS, followed by MS, where peri-operative
volume shifts and arrhythmia may lead to rapid decompensation.
Figure 11 Management of patients with severe aortic valve stenosis scheduled for non-cardiac surgery
AF, atrial fibrillation; AS, aortic stenosis; BAV, balloon aortic valvuloplasty; ECG, electrocardiogram; HF,
heart failure; LV, left ventricular; LVEF, left ventricular ejection fraction; N, no; NCS, non-cardiac surgery;
SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; TEE, transoe-
sophageal echocardiography; TTE, transthoracic echocardiography; Y, yes.
The figure provides a schematic representation of diagnostic assessment or therapy to be implemented accord-
ing to surgical risk and underlying cardiac condition.
aThis applies to treatment of complications (e.g. atrial fibrillation, heart failure). No medical therapy is recom-
mended for aortic stenosis per se.

Recommendations for management of valvular heart disease in patients undergoing non-car-
diac surgery
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ela
Clinical and echocardiographic evaluation (if not recently performed) is rec-
ommended in all patients with known or suspected VHD who are scheduled I C
for elective intermediate- or high-risk NCS.
Aortic stenosis
AVR (SAVR or TAVI) is recommended in symptomatic patients with se-
I C
vere AS who are scheduled for elective intermediate- or high-risk NCS.
In asymptomatic patients with severe AS who are scheduled for elective
high-risk NCS, AVR (SAVR or TAVI) should be considered after Heart IIa C
Team discussion.
In patients with severe symptomatic AS in need of time-sensitive NCS or in
whom the TAVI and SAVR are not feasible, BAV may be considered be- IIb C
fore NCS as a bridge to definitive aortic valve repair.
Aortic valve regurgitation
In patients with symptomatic severe AR or asymptomatic se-
vere AR and LVESD >50mm or LVESD >25mm/m2 BSA (in patients with
I C
small body size) or resting LVEF ≤50%, valve surgery is recommended prior
to elective intermediate- or high-risk NCS.
Mitral valve stenosis
In patients with moderate-to-severe rheumatic MS and symptoms
or SPAP >50 mmHg, valve intervention (PMC or surgery) is recommended I C
before elective intermediate- or high-risk NCS.
Mitral valve regurgitation
In symptomatic severe primary MR or asymptomatic severe prima-
ry MR with LV dysfunction (LVESD ≥40 mm and/or LVEF ≤60%), valve
intervention (surgical or transcatheter) should be considered prior to interme-
diate- or high-risk NCS, if time allows. In patients with severe sec-
IIa C
ondary MR who remain symptomatic despite guideline-directed medical
therapy (including CRT if indicated), valve intervention (transcatheter or
surgical) should be considered before NCS, in eligible patients with an ac-
ceptable procedural risk.
AS, aortic valve stenosis; AR, aortic regurgitation; AVR, aortic valve replacement; BAV, balloon aortic
valvuloplasty; BSA, body surface area; CRT, cardiac resynchronization therapy; MS, mitral stenosis; LV, left
ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; LVESDi,
left ventricular end-systolic dimension index; MR, mitral valve regurgitation; MS, mitral stenosis; NCS, non-
cardiac surgery; PMC, percutaneous mitral commissurotomy; SAVR, surgical aortic valve replacement; SPAP,
systolic pulmonary artery pressure; TAVI, transcatheter aortic valve implantation; VHD, valvular heart dis-
ease.
In case of symptomatic moderate-to-severe secondary MR, patients meeting the Cardiovascular Outcomes As-
sessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgita-
tion (COAPT) criteria should be considered for transcatheter edge-to-edge treatment before NCS (see Figure
14 in the guidelines).
Arrhythmias
Arrhythmias pose a significant burden to patients undergoing NCS, contributing to excessive morbidity and
mortality. All patients with known arrhythmia undergoing elective surgery should have a 12-lead ECG per-
formed pre-operatively and undergo a cardiologic check-up. Prevention of potential arrhythmic triggers is cru-
cial. Patients already taking anti-arrhythmic drugs, in general, should not stop taking these drugs. A summary
of diagnostic and therapeutic pathways in patients with supraventricular or ventricular arrhythmias is shown
in Table 8.
Table 8 Peri-operative management of patients with arrhythmias
Type of
Idiopathic VT in structurally/ VT in structural
arrhyth- SVT
functionally normal heart heart disease
mia
ECG ± echocardiographya ECG ± echocardiography ECG + echocar-
Diag-
diography +
nostics
biomarkersb
Vagal manoeuvres Vagal manoeuvres Treatment of un-
i.v. adenosine, beta- i.v. beta-blockers/ verapamil derlying heart
blocker, CCB Electrical cardioversion if disease
Acute Electrical cardioversion if unstable i.v. beta-blocker
manage- unstable (uptitration),
ment amiodarone
Electrical cardio-
version if un-
stable
Per oral beta-blocker, CCB No treatment or Per oral beta-
Catheter ablation if recur- Per oral beta-blocker, CCB, blocker, amio-
Preven- rent despite OMT (only class I AAD darone
tion of before high-risk NCS) Catheter ablation in case of Catheter ablation
recur- recurrence de- if recurrent de-
rence spite AADs or drug-intol- spite OMT
erance before high-
risk NCS
AAD, antiarrhythmic drug; CCB, calcium channel blocker; CT, computer tomography; ECG,
electrocardiogram; MRI, magnetic resonance imaging; NCS, non-cardiac surgery; OMT, optimal medical ther-
apy; SVT, supraventricular tachycardia; TTE, transthoracic echocardiography; VT, ventricular tachycardia.
aBefore high-risk surgery.
bHigh-sensitivity cardiac troponin T/I, and/or BNP/ N-terminal pro-BNP.

Premature ventricular contractions (PVC) and non-sustained ventricular tachycardia (VT) are frequent in the
general population and in patients undergoing NCS. These arrhythmias have historically been considered be-
nign; however, recent studies have suggested that they may be associated with an adverse outcome, even in
patients with apparently normal hearts, especially if frequent (e.g. >10-20%). In patients with heart disease, the
prognostic impact of PVC and non-sustained VT depends on type and extent of disease. In patients undergoing
urgent NCS, they do not require treatment unless frequent and symptomatic.
Recommendations for management of known or newly diagnosed arrhythmias
Lev-
ela
Supraventricular arrhythmias
In patients with SVT controlled by medication, it is recommended
I C
that AADs are continued during the perioperative period.
Ablation should be considered in symptomatic patients with recurrent or per-
IIa B
sistent SVT despite treatment, prior to high-risk, non-urgent NCS.
AF with haemodynamic instability in patients undergoing NCS
In AF patients with acute or worsening haemodynamic instability undergo-
I B
ing NCS, emergency electrical cardioversion is recommended.
In AF patients with haemodynamic instability, amiodarone may be consid-
IIb B
ered for acute control of heart rate.
Ventricular arrhythmias
In patients with symptomatic, monomorphic, sustained VT associated with
myocardial scar, recurring despite optimal medical therapy, ablation of ar- I B
rhythmia is recommended before elective NCS.
It is not recommended to initiate treatment of asymptomatic PVCs dur-
III C
ing NCS.
AAD, antiarrhythmic drug; AF, atrial fibrillation; NCS, non-cardiac surgery; PVCs, premature ventricular
contractions; SVT, supraventricular tachycardia; TE, thromboembolism; VT, ventricular tachycardia.
Patients with cardiac implantable electronic devices (CIED)
Patients with CIEDs can undergo NCS, pending adequate peri-operative device management. A pre-operative
check should have been performed at least once within the 12 months preceding surgery for pacemaker pa-
tients and within 6 months for patients with ICD, in the absence of any malfunction. In pacing-dependent pa-
tients, in patients with biventricular pacing for CRT, and in ICD-recipients undergoing elective NCS associat-
ed with risk of electromagnetic interference (EMI) (e.g. involving the use of unipolar electrocoagulation, espe-
cially above the umbilicus), CIED check and reprogramming should be performed immediately before surgery.
The indifferent return pad should be placed as far away from the CIED as possible, keeping the surgical site
between the CIED and the return electrode (Figure 14).
Figure 12 Optimal location of return electrode during unipolar electrosurgery in patients with cardiac im-
plantable electronic devices, depending on the surgery site
CIED, cardiac implantable electronic device.

Use of bipolar electrocautery, short (<5 s) bursts of impulses, with the lowest effective energy, operating with
pen or stylus away (>15 cm) from the device can minimize the risk of interference with the device.
A) Surgery site on ipsilateral site above CIED.
B) Surgery on ipsilateral site below CIED.
C) Surgery on contralateral site.
Recommendations for management of bradyarrhythmia and patients carrying cardiac im-
plantable devices
Lev-
ela
If indications for pacing exist according to the 2021 ESC Guidelines on car-
diac pacing and cardiac resynchronization therapy, NCS surgery should be IIa C
deferred and implantation of a permanent pacemaker should be considered.
It is recommended that patients with temporarily deactivated ICDs have con-
tinuous ECG monitoring, and during the perioperative period are accompa-
nied by personnel skilled in early detection and treatment of arrhythmias. In
I C
high-risk patients (e.g. pacemaker dependant or ICD patients), or if access to
torso will be difficult during the procedure, it is recommended to place tran-
scutaneous pacing/defibrillation pads prior to NCS.
It is recommended that all patients with CIEDs which are reprogrammed be-
fore surgery, have a re-check and necessary reprogramming as soon as possi- I C
ble after the procedure.
In high-risk CIED patients (e.g with ICD or being pacing-dependant) under-
going NCS carrying a high probability of electromagnetic interference (e.g.
involving unipolar electrosurgery above the umbilical area), CIED checkup IIa C
and necessary reprogramming immediately before procedure should be con-
sidered.
CIED, cardiac implantable electronic device; ECG, electrocardiogram; ICD, implantable cardioverter-
defibrillator; NCS, non-cardiac surgery.
Adult congenital heart disease
Adults with congenital heart disease (ACHD) represent an increasing proportion of non-cardiac surgical ad-
missions and might be at high risk for CV events. Pre-operative risk assessment in ACHD needs to focus on
the underlying disease, type of surgery, residua, and sequelae. Coexistence of HF, pulmonary hypertension,
arrhythmia, hypoxaemia, damage to other organs, and endocarditis may considerably influence the baseline
risk of these patients from no additional risk to very high risk for worse prognosis. In a recent report, absolute
mortality in ACHD patients undergoing NCS exceeded 4%. The classification in Table 9 is proposed for risk
stratification.
Table 9 Risk stratification for non-cardiac surgery in adults with congenital heart disease
Patients with small, uncorrected defects, and no need for medication or any other
Minor
treatment. Patients with successfully corrected CHD with no symptoms, no rele-
risk
vant residua, and no need for medication
Interme- Patients with corrected or uncorrected conditions with residual haemodynamic
diate abnormality, with or without medication
risk
Patients with uncorrected cyanotic heart disease, pulmonary hypertension, other
Severe
complex congenital heart disease, ventricular dysfunction requiring medication,
risk
and patients listed for heart transplantation
Recommendations for management of patients with adult congenital heart disease undergo-
ing non-cardiac surgery
Lev-
ela
In patients with ACHD, a consultation by an ACHD specialist is recom-
I C
mended before intermediate- or high-risk surgery.
In patients with ACHD, it is recommended that intermediate- and high-risk
elective surgery is performed in a centre with experience in the care I C
of ACHD patients.
ACHD, Adults with congenital heart disease.
Pulmonary arterial hypertension
PAH is associated with increased morbidity and mortality in patients undergoing NCS. A meticulous pre-oper-
ative diagnostic work-up in these patients should include assessment of functional status and severity of dis-
ease in addition to comorbidities and the type of NCS (Table 10).
In patients with severe PAH, a peri-operative mortality ranging between 3% and 18% has been reported, de-
pending on the severity of the underlying disease, and the nature and urgency of the surgical procedure. Emer-
gency procedures are also associated with a high risk of complications.
Table 10 Patient-related and surgery-related factors to be considered when assessing peri-
operative risk in patients with pulmonary arterial hypertension
Patient-related peri-operative risk factors in Patient-related peri-operative risk factors in
patients with PAH patients with PAH
Functional class >II Emergency surgery
Reduced six-minute walk distance Duration of anaesthesia >3 h
Coronary heart disease Intra-operative
Previous pulmonary embolism
Chronic renal insufficiency
Severe right ventricular dysfunction
PAH, pulmonary arterial hypertension.
Recommendations for patients with pulmonary artery hypertension undergoing non-cardiac
surgery
Lev-
ela
It is recommended to continue chronic therapy for PAH in the perioperative
I C
phase of NCS.
It is recommended that haemodynamic monitoring of patients with se-
I C
vere PAH continues for at least 24 hours in the postoperative period.
In the case of progression of right HF in the postoperative period in patients
with PAH, it is recommended that the diuretic dose be optimized and, if
I C
necessary, i.v. vasoactive drugs be initiated under the guidance of a physi-
cian experienced in the management of PAH.
Inodilator drugs (dobutamine, milrinone, levosimendan), which increase car-
diac output and lower pulmonary vascular resistance, should be considered IIa C
perioperatively according to the haemodynamic status of the patient.
HF, heart failure; i.v., intravenous; NCS, non-cardiac surgery; PAH, pulmonary arterial hypertension.
Arterial hypertension
The prevalence of arterial hypertension in adults in Europe is around 30-45%. Of these patients, <40% have a
well-controlled blood pressure (BP) (<140/90 mmHg). Overall CV risk assessment, including the search for
hypertension-mediated organ damage, is of paramount importance in hypertensive patients, and mandatory
when an elevation of BP is newly detected. Postponing surgery is usually not advised in patients with grade 1
or 2 hypertension. In contrast, in subjects with a systolic BP ≥180 mmHg and/or diastolic BP ≥110 mmHg, de-
ferring the intervention until BP is under control is advisable, except for emergency surgery. It seems also to
be important to avoid large peri-operative BP fluctuations.
The management of patients with hypertension in the pre-operative setting should follow the recommendation
provided in the 2018 ESC/ESH Guidelines for the management of arterial hypertension.
Recommendations for preoperative management of hypertension
Lev-
ela
In patients with chronic hypertension undergoing elective NCS, it is recom-
mended to avoid large perioperative blood pressure fluctuations, particularly I A
hypotension, during the perioperative period.
It is recommended to perform preoperative screening for hypertension-medi-
ated organ damage and CV risk factors in newly diagnosed hypertensive pa- I C
tients who are scheduled for elective high risk NCS.
It is not recommended to defer NCS in patients with stage 1 or 2 hyperten-
III C
sion.
Peripheral artery disease
Patients with peripheral artery disease (PAD) usually have advanced atherosclerotic disease affecting multiple
vascular beds in varying degrees and have a worse prognosis as compared with patients without PAD.
Generally, patients with PAD differ in their risk profiles according to whether they undergo vascular or non-
vascular NCS.
Recommendations for management of patients with peripheral artery disease and/or abdomi-
nal aortic aneurysm undergoing non-cardiac surgery
Lev-
ela
In patients with poor functional capacity or with significant risk factors or
symptoms (such as moderate to severe angina pectoris, decompensated HF,
I C
valvular disease, and significant arrhythmia), referral for cardiac workup and
optimization is recommended prior to elective surgery for PAD or AAA.
Routine referral for cardiac workup, coronary angiography and CPET prior
III C
to elective surgery for PAD or AAA is not recommended.
AAA, abdominal aortic aneurysm; CPET, cardiopulmonary exercise testing; HF, heart failure; PAD, peripheral
artery disease.
Cerebrovascular disease
Patients undergoing NCS should be questioned about previous neurological symptoms, and those with symp-
toms suggestive of transient ischaemic attack (TIA) or stroke in the preceding 6 months should undergo pre-
operative neurological consultation as well as neurovascular and brain imaging, if appropriate. In the absence
of dedicated studies addressing this issue, the criteria for carotid revascularization in symptomatic and asymp-
tomatic patients is described in detail in the 2017 ESC Guidelines on the diagnosis and treatment of peripheral
arterial diseases, in collaboration with the ESVS; these guidelines should also guide the management of pa-
tients with carotid disease who are undergoing NCS.
Recommendations for management of patients with suspected or established carotid artery
disease undergoing non-cardiac surgery
Lev-
ela
Preoperative carotid artery and cerebral imaging is recommended in patients
with a history of TIA or stroke in the previous 6 months who have not un- I C
dergone ipsilateral revascularization.
For patients with carotid artery disease undergoing NCS, the same indica-
tions for carotid revascularization should be considered as for other patients IIa C
with carotid stenosis.
Preoperative carotid artery imaging is not recommended routinely in patients
III C
undergoing NCS.
NCS, non-cardiac surgery; TIA, transient ischaemic attack.
Renal disease
Renal disease portends a significant increase in the post-operative risk of CV events, including MI, stroke, and
progression of HF in patients undergoing NCS. For this reason, most risk indices for the quantification of pre-
operative risk in patients undergoing NCS include renal function.
Identification of cardiac patients at risk of worsening of renal function in the peri-operative phase of NCS is of
paramount importance in order to initiate preventive measures.
Recommendations for management of patients with renal disease undergoing non-cardiac
surgery
Lev-
ela
In patients with renal disease requiring peri-operative contrast-enhanced ra-
diography, a balanced hydration with i.v. isotonic fluids, the use of a mini-
IIa B
mal volume of contrast media and the use of low-osmolar or iso-osmolar
contrast media should be considered.
In patients with known risk factors (age >65 years, BMI >30 kg/m2, diabetes,
hypertension, hyperlipidemia, CV disease or smoking) undergoing interme-
I C
diate- or high-risk NCS, it is recommended to screen for preoperative renal
disease measuring serum creatinine and GFR.
If a cystatin C measurement assay is available, cystatin C measurement
should be considered in patients with impaired eGFR (<45-59 mL/min/1.73 IIa C
m2) to confirm kidney disease.
BMI, body mass index; CV, cardiovascular; eGFR, estimated glomerular filtration rate; GFR, glomerular fil-
tration rate; i.v., intravenous; NCS, non-cardiac surgery.
Obesity
The prevalence of overweight and obesity is reaching epidemic proportions in Western countries, and is the
second leading cause of preventable death following tobacco use. Obesity is defined as a body mass index
(BMI) of ≥30 kg/m2 or greater, morbid obesity as a BMI ≥35 kg/m2, and super-morbid obesity as a BMI ≥50
kg/m2. Obese individuals have a higher prevalence of CV risk factors and a higher risk of death, and are a pop-
ulation who are at increased risk of adverse events in the case of surgical procedures.
On the one side, there exist specific recommendations for the pre-operative risk assessment of obese patients
undergoing NCS, regardless of the presence of pre-existing cardiac conditions. On the other side, while obesity
accelerates the propensity for CVD, it seems that many types of CVD may have a better prognosis in the over-
weight population compared with their leaner counterparts, a phenomenon that is known as the ‘obesity para-
dox'.
Recommendations for management of patients with obesity undergoing non-cardiac surgery
Lev-
ela
It is recommended to assess cardiorespiratory fitness to estimate periopera-
tive CV risk in the obese patient, with particular attention to those undergo- I B
ing intermediate and high-risk NCS.
In patients at high risk of obesity hypoventilation syndrome, additional spe-
IIa C
cialist investigation before major elective NCS should be considered.
Diabetes
Due to the progressive ageing of the population undergoing surgical procedures and the increasing prevalence
of obesity worldwide, the prevalence of diabetes among patients undergoing NCS is expected to increase in the
years to come.
The haemoglobin A1c (HbA1c) test should be performed in all patients with diabetes or impaired glucose
metabolism scheduled for an NCS, if this measurement has not been performed in the previous 3 months.
There is evidence to support that pre-admission optimal treatment of hyperglycaemia in patients scheduled for
elective NCS is effective in reducing the post-operative risk of CV events. Repeated blood glucose monitoring
on the day of surgery is recommended, with a general consensus to maintain peri-operative glucose levels be-
low 10.0 mmol/L without causing hypoglycaemia (target level 5.6-10.0 mmol/L). This can be achieved either
with subcutaneous doses of rapid-acting insulin analogues or with i.v. insulin. Handling of SGLT2 inhibitors in
relation to surgery is discussed in section 5.2 of the guidelines.
Recommendations for management of patients with diabetes mellitus undergoing non-car-
diac surgery
Lev-
ela
In patients with diabetes or disturbed glucose metabolism, a preopera-
tive HbA1c test is recommended, if this measurement has been not per-
I B
formed in the prior 3 months. In case of HbA1c ≥8.5% (≥69 mmol/mol)
elective NCS should be postponed, if safe and practical.
A preoperative assessment for concomitant cardiac conditions is recom-
mended in patients with DM with suspected or known CAD and those with
I C
autonomic neuropathy, retinopathy or renal disease and scheduled to under-
go intermediate- or high-risk NCS.
CAD, coronary artery disease; HbA1c, glycated haemoglobin; NCS, non-cardiac surgery.
Cancer
Due to their higher age, in general, cancer patients have a high prevalence of CV risk factors and CVD, being a
population at increased risk for adverse events in cases of NCS. It is therefore important to optimize treatment
of CV risk factors, as well as known CVD, before NCS, following the general and disease-specific recommen-
dations provided in the guidelines. Furthermore, NCS may be particularly challenging in cancer patients be-
cause of previous administration of potential cardiotoxic chemotherapy, or fibrosis due to prior radiation.
A summary of patient-related and cancer therapy-related factors that could influence peri-operative risk is
shown in Table 11. We refer readers to the 2022 ESC Guidelines on cardio-oncology for further information.
Table 11 Factors that could influence peri-operative risk during cancer surgery and preven-
tive strategies
Factors that could influence peri-operative risk
Preventive strategies
during cancer surgery
Lifestyle risk factors—smoking, obesity, Optimal management
sedentary lifestyle of CV risk factors
Poorly controlled CV risk factors— hyperten- and CVD
sion, diabetes Optimize preventive strate-
Pre-existing CVD, including cancer therapy-re- gies with respect
lated cardiovascular toxicity to VTE and arterial
Patient-
Cardiac medications increasing peri-operative thromboembolic events
related
bleeding risk (e.g. antiplatelets and anticoag- ECG monitoring for ar-
factors
ulants) rhythmias
Historical primary malignancy Correction of all proar-
Current cancer type, stage, and location rhythmic conditions
Arrhythmias (due to myocardial cancer inva-
sion, induced QT- prolongation, AF, or im-
balance of autonomic nervous system)
Previous cardiotoxic cancer treatments (espe- Ensure optimal CV moni-
cially anthracycline chemotherapy and/or toring of neoadjuvant
trastuzumab; immune checkpoint therapy
Neoadju-
inhibitors, VEGFi, fluoropyrimidine and tho- Optimize preventive strate-
vant can-
racic radiotherapy) gies with respect
cer thera-
Cancer treatments increasing peri-operative to VTE and arterial
py
bleeding risk (e.g. antiangiogenics, BTKi) thromboembolic events
Cancer treatments increasing risk of arrhyth-
mias
AF, atrial fibrillation; BTKi, Bruton tyrosine kinase inhibitors; CV, cardiovascular; CVD, cardiovascular
disease; ECG, electrocardiogram; VEGFi, vascular endothelial grow factor inhibitor; VTE, venous throm-
boembolism.
Peri-operative monitoring and anaesthesia
The decision on the optimal peri-operative strategy should be based on close exchange of clinical information
between anaesthesiologists, cardiologists, surgeons, and other relevant specialists. In addition, it is mandatory
that any proposed strategy is presented to and discussed with the patient. An informed discussion with the pa-
tient describing the planned patient pathway and expectations during the pre-, peri- and post-operative phases
of care, and what to expect from staff and surroundings, should be given using a clear, concise, and simple de-
scription.
Recommendations for peri-operative monitoring and anesthesia
Lev-
Recommendation Classa
ela
In order to preserve optimal CV stability, it is recommended to apply goal-
I A
directed haemodynamic therapy in patients undergoing high-risk NCS.
It is recommended to avoid post-operative acute pain. I B
In order to minimize the risk of post-operative organ dysfunction, it is rec-
ommended to avoid intra-operative mean arterial pressure decrease of >20% I B
from baseline values or below 60-70 mmHg for ≥10 min.
Non-aspirin NSAIDs are not recommended as first-line analgesics in pa-
III B
tients with established or high risk of CVD.
CV, cardiovascular; CVD, cardiovascular disease; NCS, non-cardiac surgery; NSAID, non-steroidal anti-in-
flammatory drug.
Peri-operative cardiovascular complications
Peri-operative myocardial infarction/injury
Peri-operative myocardial infarction/injury (PMI) is defined as acute cardiomyocyte injury (post-operative hs-
cTn T/I release) with or without accompanying symptoms, and with or without ECG or imaging evidence of
acute myocardial ischaemia. PMI can only be reliably and rapidly detected using PMI surveillance with hs-
cTn T/I measurements before, as well as serially after surgery (e.g. 24 and 48 h post-operatively).
To identify the underlying pathophysiology and to define causal therapy, systematic work-up and early differ-
entiation of primarily non-cardiac causes (e.g. severe sepsis, PE) vs. the different cardiac causes, including
type 1 MI, type 2 MI, tachyarrhythmia, and acute HF, is of major importance (Figure 13 and Figure
14). TTE is helpful in the work-up of most patients with PMI.
Figure 13 Differential diagnosis of elevated post-operative cardiac troponin concentrations
CK, creatinine kinase; cTn l, cardiac troponin I; cTn T, cardiac troponin T; MI, myocardial infarction; PMI,
peri-operative myocardial infarction/injury.
Please be aware that the accuracy of physicians' judgement in the classification of type 1 vs. type 2 MI in peri-
operative setting may be lower vs. the non-operative settings.
Figure 14 Systematic work-up (aetiology) and therapy of peri-operative myocardial infarction/injury
CCTA, coronary computed tomography angiography; ECG, electrocardiogram; Hb, haemoglobin; ICA, inva-
sive coronary angiography; MI, myocardial infarction; N, no; ST, ST-segment; Y, yes.
Most patients with type 2 MI and silent type 1 MI should be scheduled for stress imaging or CCTA/ICA as
outpatients after discharge, depending on symptoms prior to or after surgery as well as known CAD.
aOr active bleeding.
bOr other Type 2 MI trigger such as hypoxaemia, tachycardia, hypertension.
cDual antiplatelet therapy after coronary stenting.
dPossibly in combination with dabigatran 110 mg b.i.d.

Atrial fibrillation
Post-operative AF is defined as new onset AF in the immediate post-operative period. Its incidence ranges be-
tween 2-30% with peak incidence 2-4 days post- operatively. Although many post-operative AF episodes are
self-terminating and some are asymptomatic, post-operative AF has been associated with a four- to five-fold
risk of AF recurrence in the 5 years following cardiac surgery, while the risk of recurrence after NCS is less
well described. The essential principles of the prevention and management of post-operative AF are outlined
in Figure 15.
Figure 15 Prevention and management of post-operative atrial fibrillation
AAD, antiarrhythmic drug; AF, atrial fibrillation; b.p.m., beats per minute; CCB, calcium channel blocker;
HR, heart rate; LVEF, left ventricular ejection fraction.; N, no; Y, yes
aDepend on the CHA DS2VASC-score, as well as post-operative bleeding risk.
2
bIn the acute post-operative phase, unless blood pressure is high, combination of low-dose beta-blocker and
loading with digoxin is preferred to avoid hypotension.

cShould include a cardiology visit before month 3.

Peri-operative stroke
With respect to NCS, peri-operative stroke has been reported in 0.08-0.70% of patients undergoing general
surgery, in 0.2-0.9% of patients requiring orthopaedic surgery, in 0.6-0.9% of lung operations, and in 0.8-3.0%
of surgeries involving the peripheral vasculature. The associated mortality ranges from 18-26%. Peri- operative
strokes are mainly ischaemic and cardioembolic and AF is often the underlying leading condition.
In an attempt to attenuate the risk of peri-operative stroke, antiplatelet/anticoagulant treatments should be con-
tinued whenever possible throughout the peri-operative period. Alternatively, the period of drug withdrawal
should be kept as short as possible while weighting thromboembolic and haemorrhagic risks (see section 5.2 of
the guidelines). Adequate selection of the anaesthetic technique (regional vs. neuraxial vs. general anaesthe-
sia), prevention, and treatment of AF, euglycaemic control (avoiding both hyperglycaemia and hypogly-
caemia), as well as meticulous peri-operative control of blood pressure, may all contribute to reducing the risk
of peri-operative stroke.
If post-operative stroke occurs, it must trigger immediate action: angio-CT and neurology/neurosurgical con-
sultation with the goal to intervene in the case of acute thrombotic occlusion.
Recommendations for peri-operative cardiovascular complications
Lev-
ela
It is recommended to have high awareness for peri-operative CV complica-
tions combined with surveillance for PMI in patients undergoing intermedi- I B
ate- or high-risk NCS.
Systematic PMI work-up is recommended to identify the underlying patho-
I B
physiology and to define therapy.
It is recommended to treat post-operative STEMI, NSTE-ACS, acute HF,
and tachyarrhythmias in accordance with guidelines for the non-surgical set- I C
ting, after interdisciplinary discussion with the surgeon about bleeding risk.
In patients with post-operative PE of high or intermediate clinical probabili-
ty, initiation of anticoagulation is recommended without delay, while diag- I C
nostic work-up is in progress, if bleeding risk is low.
Post-operative oral anticoagulation for PE is recommended to be adminis-
I C
tered for a period of at least 3 months.
In patients with a post-operative indication for OAC, NOAC is generally
I A
recommended over VKA.
In patients with post-operative AF after NCS, long-term OAC therapy
should be considered in all patients at risk for stroke, considering the antici-
IIa B
pated net clinical benefit of OAC therapy, as well as informed patient prefer-
ences.
In patients with MINS and at low risk of bleeding, treatment with dabigatran
IIb B
110 mg orally twice daily may be considered from about 1 week after NCS.
Routine use of beta-blocker for the prevention of post-operative AF in pa-
III B
tients undergoing NCS is not recommended.
AF, atrial fibrillation; CV, cardiovascular; HF, heart failure; MI, myocardial infarction; MINS, myocardial in-
jury following non-cardiac surgery; NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral
anticoagulant; NSTE-ACS, non-ST-elevation acute coronary syndrome; OAC, oral anticoagulant; PE, pul-
monary embolism; PMI, peri-operative myocardial infarction/injury; STEMI, ST-segment elevation myocar-
dial infarction; VKA, vitamin K antagonist.
Central illustration
There exists a complex interplay between the intrinsic risk of surgery and the patient-related risk of peri-opera-
tive CV complications. This latter risk depends on the baseline general and CV status of patients scheduled
for NCS. For each patient, the proper quantification and communication of the surgical risk requires a close
cooperation between cardiologists, surgeons, anaesthesiologists, general practitioners, and other healthcare
providers.
Figure 16 Central illustration
Abbreviations
(N)OAC (Non-vitamin K antagonist) oral anticoagulant

°C Degree Celsius
2D/2-D Two-dimensional
2hPG 2-h post-load plasma glucose
3D/3-D Three-dimensional
5-FU 5-fluorouracil
6MWT 6-minute walk test/6-minute walk test distance
99mTc-DPD Technetium-99m 3,3-diphosphono-1,2-propanodicarboxylic acid
99mTc-PYP Technetium labelled 99mTc-pyrophosphate
A-V Arterio-venous
A/C Anticoagulation
AAA Abdominal aortic aneurysm
AAD anti-arrhythmic drug
AADs Antiarrhythmic drugs
AAOCA Anomalous aortic origin of a coronary artery
AAOLCA Anomalous aortic origin of the left coronary artery
AAS Acute aortic syndrome
ABC Age, biomarkers, clinical history/Atrial fibrillation Better Care
ABI Ankle-Brachial Index
ABPM Ambulatory BP monitoring
ACA Aborted cardiac arrest
ACAPA Anomalous coronary artery from the pulmonary artery
ACC American College of Cardiology
ACCA Acute Cardiovascular Care Association
ACCF American College of Cardiology Foundation
ACCOAST Comparison of Prasugrel at the Time of Percutaneous Coronary Interven-
tion or as Pretreatment at the Time of Diagnosis in Patients with Non-ST
Elevation Myocardial Infarction
ACE Angiotensin-converting enzyme
ACE-I(s) Angiotensin-converting enzyme inhibitor(s)
ACEF Age, creatinine, ejection fraction
ACEI/ACE-I/ Angiotensin converting enzyme inhibitors
ACE-Is
ACHD Adult congenital heart disease/Adults with congenital heart disease
ACM Arrhythmogenic cardiomyopathy
ACNAP Association of Cardiovascular Nursing & Allied Professions
ACP AmplatzerTM Cardiac Plug
ACR Albumin-to-creatinine ratio
ACS Acute coronary syndrome
ACT Activated clotting time
ACVC Association for Acute CardioVascular Care
AD Aortic dissection
ADA American Diabetes Association/Adenosine deaminase
ADD Acute aortic dissection
ADHF Acutely decompensated heart failure
ADP Adenosine diphosphate
AECG Ambulatory electrocardiographic monitoring
AED automated external defibrillator
AEPC Association for European Paediatric and Congenital Cardiology
AF Atrial flutter/Atrial fibrillation
AFL Atrial flutter
AFNET German Competence NETwork on Atrial Fibrillation
AH Atrial to His interval
AHA American Heart Association
AHF Acute heart failure
AHRE Atrial high rate episodes
AINR International normalized ratio
AK Alpha kinase
AKI Acute kidney injury
AL Amyloid light chain
ALAT/ALT Alanine aminotransferase
ALCAPA Anomalous left coronary artery from the pulmonary artery
ALI Acute limb ischaemia
ALP Alkaline phosphatase
ALS advanced life support
AMI Acute myocardial infarction/Acute mesenteric ischaemia
ANA Anti-nuclear antibodies
ANCA Anti-neutrophil cytoplasm antibodies
AO Aorta
AOCA Anomalous origin of coronary arteries
AOS Aneurysms-osteoarthritis syndrome
AP Accessory pathway
APAH Conditions associated with pulmonary arterial hypertension
Apo Apolipoprotein
apoAI Apolipoprotein A I
apoB Apolipoprotein B
aPTT Activated partial thromboplastin time
AR Aortic regurgitation/aortic valve regurgitation
ARB Angiotensin II receptor blocker/ Angiotensin receptor blocker
ARBs Angiotensin receptor blockers/angiotensin II receptor blockers
ARC-HBR Academic Research Consortium - high bleeding risk
ARCAPA Anomalous right coronary artery from the pulmonary artery
ARNI Angiotensin receptor neprilysin inhibition
ARV arrhythmogenic right ventricular cardiomyopathy
ARVC Arrhythmogenic right ventricular cardiomyopathy
AS Aortic stenosis/aortic valve stenosis
ASA Acetylsalicylic acid
ASAT/AST Aspartate aminotransferase
ASCERT American College of Cardiology Foundation–Society of Thoracic Sur-
geons Database Collaboration
ASCVD Atherosclerotic cardiovascular disease
ASD Atrial septal defect
ASE American Society of Echocardiography
ASI Aortic size index
AST/ALT/ Aspartate / alanine aminotransferase / alkaline phosphatase
ALP
ASV Adaptive servo-ventilation
AT Atrial tachycardia/Antithrombin
ATOR Atorvastatin
ATP Antitachycardiac pacing/Adenosine triphosphate
ATRIA AnTicoagulation and Risk factors In Atrial fibrillation
ATS Arterial tortuosity syndrome
ATTR Amyloidosis, transthyretin type
AUC Area under the curve
AUGUSTUS Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial
Fibrillation
AV Atrioventricular/Arteriovenous
AVA Aortic valve area
AVB Atrioventricular block
AVID Antiarrhythmic drugs Versus Implantable Defibrillator
AVJ Atrioventricular junction
AVM AV delay management
AVN Atrioventricular node
AVNRT Atrioventricular nodal reentrant tachycardia
AVP Arginine vasopressin
AVR Aortic valve replacement
AVRT Atrioventricular re-entrant tachycardia
AVSD Atrioventricular septal defect
b.i.d. Bis in die (twice daily)
b.p.m/bpm Beats per minute
BARC Bleeding Academic Research Consortium
BARI-2D Bypass Angioplasty Revascularization Investigation 2 Diabetes
BAS Balloon atrial septostomy
BAV Balloon aortic valvuloplasty/Bicuspid aortic valve
BB Beta-blocker
BBB Bundle branch block
BBR-VT bundle branch re-entrant ventricular tachycardia
BC Blood culture
BCNIE Blood culture-negative infective endocarditis
BCR-ABL Breakpoint cluster region-Abelson
BGA Blood gas analysis
BHV Biological heart valve
Bi-PAP Bilevel positive airway pressure
BIMA Bilateral internal mammary artery
BiV/BV Biventricular
BiVAD Bi-ventricular assist device
BMI Body mass index
BMPR Bone morphogenetic protein receptor, type 2
BMS Bare metal stent
BMT Best medical therapy
BNP Brain natriuretic peptide/B-type natriuretic peptide
BP Blood pressure
BPA Balloon pulmonary angioplasty
BRS Bioresorbable vascular scaffold
BrS Brugada syndrome
BSA Body surface area
BTB Bridge to bridge
BTC Bridge to candidacy
BTD Bridge to decision
BTR Bridge to recovery
BTKi Bruton tyrosine kinase inhibitors
BTT Bridge to transplantation
BUN Blood urea nitrogen
BVF Bioprosthetic valve failure
C2HEST CAD/COPD (1 point each), Hypertension (1 point), Elderly (≥75 years, 2
points), Systolic heart failure (2 points), and Thyroid disease (hyperthy-
roidism, 1 point)
CA cardiac arrest
CABG Coronary artery bypass graft(ing)/ Coronary artery bypass graft surgery
CAC Coronary artery calcium
CAD Coronary artery disease
CAG Coronary artery angiogram
CAS Carotid artery stenting
CASH Cardiac Arrest Study Hamburg
Cath/Lab Catheterization laboratory
CCB Calcium channel blocker
CCBs Calcium channel blockers
CCD Cardiac conduction disease (or disorder)
CCNAP Council on Cardiovascular Nursing and Allied Professions
CCP Council for Cardiology Practice
CCPC Council on Cardiovascular Primary Care
CCS Canadian Cardiovascular Society/Chronic coronary syndrome
CCT Cardiovascular computed tomography/Cardiac computed tomography
CCTA Coronary computed tomography angiography
ccTGA Congenitally corrected transposition of the great arteries
CCU Coronary care unit
CDRIE Cardiac device-related infective endocarditis
CEA Carotid endarterectomy/Carcinoembryonic antigen
CETP Cholesteryl ester transfer protein
CFA Common femoral artery
CFC Cardiofaciocutaneous
CHA2DS2- Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus,
VASc Stroke, Vascular disease, Age 65–74 years, Sex category (female)
CHADS2 Cardiac failure, Hypertension, Age, Diabetes, Stroke (doubled)
CHARM- Candesartan in Heart Failure: Assessment of Reduction in Mortality and
Added Morbidity-Added
CHD Coronary heart disease/Congenital heart disease
CHF Congestive heart failure/Chronic heart failure
CHT Council on Hypertension
CI Cardiac index/Contra-indication/Confidence interval
CI-AKI Contrast-induced acute kidney injury
CI-CSS Cardioinhibitory carotid sinus syndrome
CIA Common iliac artery
CIDS Canadian Implantable Defibrillator Study
CIED Cardiac implantable electronic device
CIEDs Cardiac implantable electronic devices
CIID Chronic immune-mediated inflammatory diseases
CIN Contrast-induced nephropathy
CK Creatine phophokinase/Creatinine kinase
CK-MB Creatine kinase MB isoform
CKD Chronic kidney disease
CKD-EPI Chronic Kidney Disease Epidemiology Collaboration
CLI Chronic limb ischaemia
CLTI Chronic limb-threatening ischaemia
Cmax maximum serum concentration
CMI Chronic mesenteric ischaemia
CMP Cardiomyopathy
CMR Cardiac magnetic resonance/Cardiovascular magnetic resonance
CMV Cytomegalovirus
CO Cardiac output
CoA Coarctation/Coarctation of the aorta
COC of ESC Cardio-Oncology Council of the European Society of Cardiology
Cons Conservative
cont Continued
COPD Chronic obstructive pulmonary disease
COT Cardiac Oncology Toxicity
COURAGE Clinical Outcomes Utilization Revascularization and Aggressive Drug
Evaluation
COX Cyclo-oxygenase/Cyclooxygenase
DPAH drug-associated pulmonary arterial hypertension
CPAP Continuous positive airway pressure
CPET Cardiopulmonary exercise testing
CPFE Combined pulmonary fibrosis and emphysema
CPG Committee for Practice Guidelines
CPR cardiopulmonary resuscitation
CPVT Catecholaminergic polymorphic ventricular tachycardia
CR Cardiac rehabilitation
CrCI Creatinine clearance
CRP C-reactive protein
CRT Cardiac resynchronization therapy
CRT-D Cardiac resynchronization therapy defibrillator/Defibrillator with cardiac
resynchronization therapy
CRT-P Cardiac resynchronization therapy pacemaker
CRUSADE Can Rapid risk stratification of Unstable angina patients Suppress ADverse
outcomes with Early implementation of the ACC/AHA guidelines
CS cancer survivors
CSF Colony-stimulating factor/Cerebrospinal fluid
CSM Carotid sinus massage
CSS Carotid sinus syncope/syndrome
CT Computed tomographic/tomogram/tomography
CTA Computed tomography angiography
CTCA Computed tomography coronary angiography
CTD Connective tissue disease
CTEPH Chronic thromboembolic pulmonary hypertension
CTI Cavotricuspid isthmus
cTN Cardiac troponin
cTn l cardiac troponin I
cTn T cardiac troponin T
cTnT-hs High-sensitivity cardiac troponin T
CTO Chronic total occlusions
CTPA Computed tomography pulmonary angiography
CTR-CVT cancer therapy-related cardiovascular toxicity
CTRCD Cancer Therapeutics–Related Cardiac Dysfunction
Ctrl Control
CULPRIT- Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock
SHOCK
CUS Compression venous ultrasonography
CV Cardiovascular/Cardioversion
CVD Cardiovascular disease/Cardiovascular heart disease
CVOT Cardiovascular outcome trial
CVOTs Cardiovascular outcome trials
CVRF cardiovascular risk factor
CW Continuous wave
CXR Chest X-ray
CYP Cytochrome P
CYP2D6 Cytochrome P450 2D6
DADs Delayed afterdepolarizations
DALYs Disability adjusted life years
DAPT Dual (oral) antiplatelet therapy/Dual antiplatelet therapy
DAT Dual antithrombotic therapy
DBP Diastolic blood pressure
DC Direct current
DCB Drug-coated balloon
DCC Direct-current cardioversion
DCM Dilated cardiomyopathy
DCRV Double-chambered right ventricle
DDD Dual-chamber, atrioventricular pacing
DDI Drug-drug interactions
DEFINITE DEFibrillator In Non-Ischemic cardiomyopathy Treatment Evaluation
DES Drug-eluting stent
DFT Defibrillation threshold
DHA Docosahexaenoic acid
DHP Dihydropyridine
DHP-CCB Dihydropyridine calcium channel blockers
DI-DO Door-in to door-out time
DIAL Diabetes lifetime-perspective prediction
DLCN Dutch Lipid Clinic Network
DLCO Carbon monoxide diffusing capacity
DM Diabetes mellitus
DNA Deoxyribonucleic acid
DOAC Direct oral anticoagulant
DOACs Direct oral anticoagulants
DPAH Drug induced PAH
DPD 3,3-diphosphono1,2-propanodicarboxylic acid
DPG Diastolic pressure gradient
DPP Diabetes prevention program
DPP4 Dipeptidyl peptidase-4
DSA Digital subtraction angiography/ultrasound
DSE Dobutamine stress echocardiography
DSP Desmoplakin
DT Deceleration time
DTB Door-to-balloon time
DTIs Direct thrombin inhibitors
DUS Duplex ultrasonography/Doppler ultrasound/Duplex ultrasound
DVI Doppler velocity index/dimensionless index
DVT Deep vein thrombosis
E/A Ratio of mitral peak velocity of early filling (E) to mitral peak velocity of
late filling (A)
E/e’ Ratio of early transmitral flow velocity (E) to early mitral annulus velocity
(e’)
EACPR European Association for Cardiovascular Prevention & Rehabilitation
EACTS European Association of Cardio-Thoracic Surgery/ European Association
for Cardio-Thoracic Surgery
EACVI/EAV- European Association of Cardiovascular Imaging
CI
EANM European Association of Nuclear Medicine
EAPC European Association of Preventive Cardiology
EAPCI European Association of Percutaneous Cardiovascular Interventions
EAS European Atherosclerosis Society
EASD European Association for the Study of Diabetes
EBV Epstein-Barr virus
ECG Electrocardiogram/Electrocardiographic
ECGs Electrocardiograms
ECHO Echocardiography/Echocardiogram
ECLS Extracorporeal life support
ECMO Extracorporeal membrane oxygenation
ECST/ESCT European Carotid Surgery Trial
ECV Electrical cardioversion
ECVF Extacellular volume fraction
ED Erectile dysfunction/Emergency department
EDS Ehlers Danlos syndrome
EDS-IV Ehlers-Danlos syndrome type IV
EDV End-diastolic velocity
EE Edge to edge
EF Ejection fraction
eGFR Estimated glomerular filtration rate
EHRA European Heart Rhythm Association
EIA External iliac artery
EIF Eukaryotic translation initiation factor
EMA European Medicines Agency
EMB Endomyocardial biopsy
EMS Emergency medical system/service
ENA Anti-extractable nuclear antigens
Enox Enoxaparin
ENTRUST Edoxaban treatment versus VKA in patients with AF undergoing PCI
EP Electrophysiology/electrophysiological
EPA Eicosapentaenoic acid
EPD Embolic protection device
EPS Electrophysiologic study
ER Extended release formulations
ERA Endothelin receptor antagonist
EROA Effective regurgitant orifice area
ERP Effective refractory period
ERS European Respiratory Society
ESC European Society of Cardiology
ESCMID European Society of Clinical Microbiology and Infectious Diseases
ESD Endsystolic diameter
ESH European Society of Hypertension
ESO European Stroke Organisation
ESR European Society of Radiology/Erythrocyte sedimentation rate
ESRD End-stage renal disease
ESVS European Society for Vascular Surgery
ET Exercise test
ETT Endotracheal tube
EU European Union
EULAR European League Against Rheumatism
EuroSCORE European System for Cardiac Operative Risk Evaluation
EVAR Endovascular aortic repair/reconstruction
EVT Endovascular therapy
Ex-R Exercise-related
exCR Exercise-based cardiac rehabilitation
Exp++ Experimental therapy
FAME-2 Fractional Flow Reserve-Guided Percutaneous Coronary Intervention Plus
Optimal Medical Treatment Versus Optimal Medical Treatment Alone in
Patients With Stable Coronary Artery Disease
FBN1 Fibrillin 1
FC Functional class
FCH Familial combined hyperlipidaemia
FCM Ferric carboxymaltose
FDA US Food and Drug Administration/Food and Drug Administration
FDG Fluorodeoxyglucose
FFP Fresh frozen plasma
FFR Fractional flow reserve
FH Familial hypercholesterolaemia
FHL1 Four and a half LIM domains 1
FI Finland
FIIa factor IIa
FINDRISC FINnish Diabetes RIsk SCore
FITT Frequency intensity time and type
FL False lumen
FLN Filamin
FLNC Filamin C
FLUVA Fluvastatin
FMC First medical contact
FMCTB First-medical-contact-to-balloon time
FMF Familial Mediterranean fever
FOCUS focused cardiac ultrasound
Fonda Fondaparinux
FPG Fasting plasma glucose
FU Follow-up
FXa factor Xa
GDF-15 Growth differentiation factor-15
GDMT Guideline-directed medical treatment therapy
GFR Glomerular filtration rate/Estimated glomerular filtration rate
GGTP Gamma-glutamyl transpeptidase
GI Gastrointestinal
GLP Glucagon-like peptide
GLP-1RA/ Glucagon-like peptide-1 receptor agonist
GLP1
GLS Global longitudinal strain
GM Granulocyte-macrophage
GP Glycoprotein/General practitioner
GPI glycoprotein IIb/IIIa inhibitors
GPIIb/IIIa Glycoprotein IIb/IIIa
GRACE Global Registry of Acute Coronary Events 2.0
GSV Great saphenous vein
GUCH Grown-up patients with congenital heart disease
H-FABP Heart-type fatty acid-binding protein
H-ISDN Hydralazine and isosorbide dinitrate
HA His to atrial interval
HAART Highly active antiretroviral treatment
HACEK Haemophilus parainfluenzae, H. aphrophilus, H. paraphrophilus, H. in-
fluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium homin-
is, Eikenella corrodens, Kingella kingae, and K. denitrificans
HALT Hypo-attenuated leaflet thickening
HAS-BLED Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or
predisposition, Labile INR, Elderly (65), Drugs concomitantly/alcohol
abuse
HB Haemoglobin
HbA1c Glycated haemoglobin/Glycated haemoglobin A1c
HBP His bundle pacing
HBPM Home BP monitoring
HBR High bleeding risk
HCM Hypertrophic cardiomyopathy
HCV Hepatitis C virus
HDAC Histone deacetylase
HDL High density lipoprotein
HDL-C High density lipoprotein-cholesterol
HeFH Heterozygous familial hypercholesterolaemia
HER2 Human epidermal growth factor receptor 2
HF Heart failure
HFA Heart Failure Association
HFA-EACVI Heart Failure Association-European Association of Cardiovascular Imag-
ing
HFA-ESC Heart Failure Association-European Society of Cardiology
HFA-ICOS Heart Failure Association-International Cardio-Oncology Society
HFmrEF Heart failure with mid-range ejection fraction
HFpEF/HF- Heart failure with preserved ejection fraction
PEF
HFrEF/HF- Heart failure with reduced ejection fraction
REF
HHD Hypertensive heart disease
HHV Human herpesvirus
HIIT High-intensity interval training
HIT Heparin-induced thrombocytopenia
HITS High intensity transient signal
HIV Human immunodeficiency virus
HMDP Hydroxymethylene diphosphonate
HMOD Hypertension-mediated organ damage
HNDC Hypokinetic non dilated cardiomyopathy
HNDCM hypokinetic non-dilated cardiomyopathy
HoFH Homozygous familial hypercholesterolaemia
HOT-CRT His-optimized cardiac resynchronization therapy
HPAH Heritable PAH
HPS His-Purkinje system
HR Heart rate
HRCT High resolution CT
HRmax Maximal heart rate
HRR Heart rate reserve
HRs Heart failures
hs-CRP High-sensitivity C-reactive protein
Hs-cTn High-sensitivity cardiac troponin
HT Heart transplantation
HT/HTN Hypertension
HTAD Heritable/hereditary thoracic aortic disease
HTG Hypertrigiyceridaemia
HTM Home telemonitoring
HTx Heart transplantation
HV His-ventricular interval (time from the beginning of the H deflection to the
earliest onset of ventricular depolarization recorded in any lead, electro-
physiology study of the heart)
i.v./IV Intravenous
IABP Intra-aortic balloon pump
IABP- Intra-Aortic Balloon Pump in Cardiogenic Shock II
SHOCKII
IART Intraatrial reentrant tachycardia
IAS Inter-atrial septum
ICA Invasive coronary angiography
ICCU Intensive cardiac care unit
ICD Implantable cardioverter defibrillator/International Classification of Dis-
eases
ICDs Implantable cardioverter defibrillators
ICH Intracranial haemorrhage
ICI immune checkpoint inhibitor
ICM Insertable cardiac monitor
ICOS International Cardio-Oncology Society
ICU Intensive care unit
ID Infectious disease
IDF International Diabetes Federation
IDL Intermediate-density lipoproteins
IE Infective endocarditis
IFG Impaired fasting glucose
IFN Interferon-gamma
iFR Instantaneous wave-free ratio
IGRA Interferon-gamma release assay
IGT Impaired glucose tolerance
IHD Ischaemic heart disease
IL-2 Interleukin 2
ILR Implantable loop recorder
IMA Internal mammary artery
IMH Intramural haematoma
IMiD immunomodulatory drug
IMR Index of microcirculatory resistance
IMT Intima–media thickness
IN-TIME Implant-based multiparameter telemonitoring of patients with heart failure
INR International normalized ratio
INRs International normalized ratios
INTERMACS Interagency Registry for Mechanical Assisted Circulatory Support
IOMC Iso-osmolar contrast medium
IPAH Idiopathic pulmonary arterial hypertension
IPF Idiopathic pulmonary fibrosis
IRA Infarct related artery
ISAR-REACT Intracoronary stenting and Antithrombotic regimen–Rapid Early Action for
Coronary Treatment
ISDN Isosorbide dinitrate
ISH Isolated systolic hypertension
ISHLT International Society for Heart and Lung Transplantation
IU International units
IUD Intrauterine device
IVC Inferior vena cava
IVDA Intravenous drug abusers
IVIG Intravenous immunoglobulin
IVUHF Intravenous unfractionated heparin
IVUS Intravascular ultrasound
iwFR instantaneous wave-free ratio
JET Junctional ectopic tachycardia
JSAP Japanese Stable Angina Pectoris
JT Junctional tachycardia
KDOQI Kidney Disease Outcomes Quality Initiative
kmperh Kilometres per hour
L–R Left-to-right
LA Left atrium/left atrial
LAA Left atrial appendage
LAD Left anterior descending (coronary artery)
LAE Left atrial enlargement
LAH Left anterior hemiblock
LAN Long-acting nitrate
LAVI Left atrial volume index
LBBB Left bundle branch block
LCC Left coronary cusp
LCSD left cardiac sympathetic denervation
Lcx Left circumflex
LD Loading dose
LDH Lactate dehydrogenase
LDL Low-density lipoprotein
LDL-C Low-density lipoprotein-cholesterol
LDLR Low density lipoprotein receptor
LDS Loeys-Dietz syndrome
LEAD Lower-extremity artery disease
LEOPARD Lentigines, ECG abnormalities, ocular hypertelorism, pulmonary stenosis,
abnormal genitalia, retardation of growth, and sensorineural deafness
LGE Late gadolinium enhancement
LGE-CMR Late gadolinium contrast-enhanced cardiac magnetic resonance
LHD Left heart disease
LIFE-CVD LIFEtime-perspective CardioVascular Disease
LLN Lower limit of normality
LM Left main/ Left main coronary artery
LMNA Lamin A/C
LMWH Low molecular weight heparin
LOCM Low-osmolar contrast medium
LoE Level of evidence
LOVA Lovastatin
Lp Lipoprotein
Lp(a) Lipoprotein(a)
LQT long QT syndrome
LQTS Long QT syndrome
LSD Lysergic acid diethylamide
LT-MCS Long-term mechanical circulatory support
LTBI Latent tuberculosis infection
LTx lung transplantation
LUS Lung ultrasound
LV Left ventricle/left ventricular
LVAD Left ventricular assist devices
LVAD-BTC Left ventricular assist device – bridge to candidacy
LVAD-DT Left ventricular assist device – destination therapy
LVADs Left ventricular assist devices
LVD Left ventricular dysfunction
LVEDD Left ventricular end-diastolic diameter
LVEDP Left ventricular end diastolic pressure
LVEF Left ventricular ejection fraction
LVESD Left ventricular end-systolic diameter
LVESDi left ventricular end-systolic dimension index
LVESV Left ventricular end-systolic volume
LVESVI Left ventricular end-systolic volume index
LVF Left ventricular function
LVH Left ventricular hypertrophy
LVM Left ventricular mass
LVMI Left ventricular mass index
LVNC Left ventricular non-compaction
LVOT Left ventricular outflow tract
LVOTG Left ventricular outflow tract gradient
LVOTO Left ventricular outflow tract obstruction
LVSD Left ventricular systolic dysfunction
MAC Mitral annular calcification
MACE Major adverse cardiac events
MADIT Multicenter Automatic Defibrillator Implantation Trial
MAPCAs Major aortic pulmonary collaterals
MASSII The medicine, angioplasty, or surgery study
MB Myocardial bridge/bridging
Mbq Millibecquerel
MCS/MSC Mechanical circulatory support
MD Maintenance dose
MDCT Multidetector computed tomographic angiography/Multi-detector comput-
ed tomography
MDRD Modifikation of Diet in Renal Disease
MDT multidisciplinary team
MedPed Make Early Diagnosis to Prevent Early Deaths
MedRX Medial therapy
MEK Mitogen-activated protein kinase
MELAS Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like
episodes
MERFF Myoclonic epilepsy with ragged red fibres
MET Metabolic equivalent
MetS Metabolic syndrome
MFS Marfan syndrome
MHV Mechanical heart valve
MHVs Mechanical heart valves
MI Myocardial infarction
MIC Minimum inhibitory concentration
MIDA Mitral Regurgitation International Database
MINOCA Myocardial infarction with non-obstructive coronary arteries
MINS myocardial injury following non-cardiac surgery
MM multiple myeloma
mo. month(s)
mPAP mean pulmonary arterial pressure
MPI Myocardial perfusion imaging
MPR Multiplanar reconstruction
MPS Myocardial perfusion scintigraphy/Myocardial perfusion stress
MR Magnetic resonance/ Mitral regurgitation/Mineralocorticoid receptor
MR-proANP Mid-regional pro atrial natriuretic peptide/Mid-regional pro A-type natri-
uretic peptide
MRA Mineralocorticoid receptor antagonist/Magnetic resonance angiography
MRAs Mineralocorticoid receptor antagonists
MRAT Macro-reentrant atrial tachycardias
MRI Magnetic resonance imaging
MRIs Magnetic resonance imagings
MRSA Methicillin-resistant Staphylococcus aureus
MS Mitral stenosis
ms milliseconds
MSAD Multisite artery disease
MSCT Multislice computed tomography
MSSA Methicillin-susceptible Staphylococcus aureus
mSv Millisievert
MT Medical therapy
MTP Microsomal triglyceride transfer protein
MUFA Monounsaturated fatty acid
MUFAs Monounsaturated fatty acids
MUGA Multigated radionuclide angiography
mV millivolt(s)
MVA Mitral valve area
MVabn Mitral valve abnormality
MVD Multivessel CAD
MVP Mitral valve prolapse
MVR Mitral valve replacement or repair
MVT monomorphic ventricular tachycardia
MWD Minute walk distance
MWT Minute walk test
MYBPC3 Myosin-binding protein C
MYH7 Myosin, heavy chain 7
MYL3 Essential myosin light chain
N no
n.a/NA not available/ Not available
N/A Not applicable
N/R Not reported
NAFLD Non-alcoholic fatty liver disease
NASCET North American Symptomatic Carotid Endarterectomy Trial
NCC Non coronary cusp
NCDR National cardiovascular data registry
NCS Non-cardiac surgery
NDCC Nondihydropyridine calcium channel
NDHP-CCB Non-dihydropyridine calcium channel blocker
NIHSS National Institutes of Health stroke severity scale
NIPPV Non-invasive positive pressure ventilation
NIV Non-invasive ventilation
NNH Numbers needed to harm
NNT Numbers needed to treat/ Number of individuals needed to treat
NOAC Non-vitamin K antagonist oral anticoagulant
NOACs Non-vitamin K antagonist oral anticoagulants
Non-HDL-C Non-HDL cholesterol
NP Natriuretic peptide
NPs Natriuretic peptides
NPV Negative predictive value
NR No recommendation
NRT Nicotine replacement therapy
NSAID Non-steroidal anti-inflammatory drug
NSAIDs Non-steroidal anti-inflammatory drugs
NSQIP National surgical quality improvement program
NSTE Non-ST-elevation
NSTE-ACS Non-ST-segment elevation acute coronary syndrome/ Non-ST elevation
acute coronary syndrome
NSTEMI Non-ST-elevation myocardial infarction
NSVT Non-sustained ventricular tachycardia
NT-ProBNP N-terminal (NT)-prohormone B-type natriuretic peptide
NTG Nitroglycerine
NTproBNP N terminal pro B type natriuretic peptide
NVE Native valve endocarditis
NYHA New York Heart Association
o.d. omni die (once daily)
O2 Oxygen
OAC Oral anticoagulation/anticoagulant
OARS Open-ended questions, Affirmation, Reflective listening, Summarising
OCT Optical coherence tomography
OD Organ damage
ODYSSEY Evaluation of Outcomes Cardiovascular Outcomes After an Acute Coro-
nary Syndrome During Treatment With Alirocumab
OGTT Oral glucose tolerance test
OHCA Out-of-hospital cardiac arrest
OHS Obesity hypoventilation syndrome
OMT Optimal medical therapy
OR Odds ratio
ORBIT Outcomes Registry for Better Informed Treatment of Atrial Fibrillation
OSA Obstructive sleep apnoea
p.o. Per os
PA Postero-anterior/Pulmonary artery/Physical activity
PAD Peripheral artery disease
PADs Peripheral arterial diseases
PAH Pulmonary arterial hypertension/Pulmonary hypertension
PaO2 Partial pressure of oxygen
PAP Pulmonary artery pressure/Pulmonary arterial pressure
PAR Protease-activated receptor
PAU Penetrating aortic ulcer
PAWP Pulmonary artery wedge pressure
PCA Prostacyclin analogues
PCC Prothrombin coagulation complax/Prothrombin complex concentrates
PCH Pulmonary capillary haemangiomatosis
PCI Percutaneous coronary intervention
PCIS Post-cardiac injury syndromes
PCR Polymerase chain reaction
PCSK9 Proprotein convertase subtilisin kexin 9
PCWP Pulmonary capillary wedge pressure
PDA Patent ductus arteriosus
PDE Phosphodiesterase type-5 inhibitors/Phosphodiesterase
PDE5 Phosphodiesterase type 5
PE Pulmonary embolism
PEA Pulmonary endarterectomy
PEP Primary endpoint
PERT Pulmonary Embolism Response Team
PES programmed electrical stimulation
PESI Pulmonary embolism severity index
PET Positron emission tomography
PET-CT positron emission tomography and computed tomography
PF Physical fitness
PFT Pulmonary function tests
PH Pulmonary hypertension
PI proteasome inhibitor
PISA Proximal isovelocity surface area
PICO population/problem, intervention, comparison, outcomes
PITA Pitavastatin
PJRT Permanent junctional reciprocating tachycardia
PLN Phospholamban
PM Pacemaker/Pain management
PMI peri-operative myocardial infarction/injury
PMC Percutaneous mitral commissurotomy
PMR Primary mitral regurgitation
POAF Postoperative AF
POCT Point-of-care test
PoPH PAH associated with portal hypertension
PPAR Peroxisome proliferator-activated receptor
PPCM Peripartum cardiomyopathy
PPI Proton pump inhibitor
PPIs Proton pump inhibitors
PPM Patient Patient-prosthesis mismatch/Permanent pacemaker
PPS Post-pericardiotomy syndrome
PR Pulmonary regurgitation/PR interval
PRAVA Pravastatin
PRECISE- PREdicting bleeding Complications In patients undergoing Stent implanta-
DAPT tion and subsEquent Dual Anti Platelet Therapy
PRIMARYP- Primary percutaneous coronary intervention
CI
PRKAG2 Gamma-2 subunit of the adenosine monophosphate-activated protein ki-
nase
PRO Patient-reported outcome
PROM Patient risk of mortality
PROs Patient-reported outcomes
PS Pulmonary valve stenosis/Pulmonary stenosis
PSVT Paroxysmal supraventricular tachycardia
PTA Percutaneous transluminal angioplasty/Pre-test probability
PTP Pre-test probability
PTT Partial thromboplastin time
PUFA Polyunsaturated fatty acid
PUFA/PUFAs Polyunsaturated fatty acid/Polyunsaturated fatty acids
PUFAs Polyunsaturated fatty acids
PV Pulmonary valve
PVC Premature ventricular contraction/Premature ventricular complex
PVCs premature ventricular complexes
PVE Prosthetic valve endocarditis
PVI Pulmonary vein isolation
PVL Paravalvular leak
pVO2 Peak exercise oxygen consumption
PVOD Pulmonary veno-occlusive disease
PVR Pulmonary vascular resistance
PVRep Pulmonary valve replacement
PVS Programmed ventricular stimulation
PVT ventricular tachycardia
PWV Pulse wave velocity
QI Quality Indicator
QoL Quality of life
Qp:Qs Pulmonary to systemic flow ratio
QRS QRS interval
QT QT interval
QTc Corrected QT interval
QTcF Fridericia correction
r-PA Reteplase
RA Right atrium/Rheumatoid arthritis
RAA Renin-angiotensin-aldosterone
RAAS Renin-angiotensin-aldosterone system
RAD Renal artery disease
RAP Right atrial pressure
RAS Renal artery stenosis/Renin-angiotensin system
RBBB Right bundle branch block
RBC Red blood cell
RCC Right coronary cusp
RCRI Revised Cardiac Risk Index
RCT/RCTs Randomized controlled trials
RF Risk factor
rFVIIa Activated recombinant factor VII
RHC Right heart catheterization
RHD Rheumatic heart disease
RM Repetition maximum
RNA Ribonucleic acid
ROSU Rosuvastatin
RP RP interval
rPA Recombinant plasminogen activator/Right pulmonary artery
RPE Rating of perceived exertion
RPG Random plasma glucose
RR Relative risk
RRR Relative risk reduction
RRT Renal replacement therapy
RS Beginning of R to deepest part of S
RT radiotherapy
rTOF repaired tetralogy of Fallot
rtPA Recombinant tissue plasminogen activator
RV Right ventricle/right ventricular
RVA Right ventricular apical
RVAD Right ventricular assistance device
RVEDP Right ventricular end-diastolic pressure
RVEDVi Right ventricular end diastolic volume indexed
RVESVi Right ventricular end systolic volume indexed
RVH Right ventricular hypertrophy
RVol Regurgitant volume
RVOT Right ventricular outflow tract
RVOTO Right ventricular outlow tract obstruction
RVS Right ventricular septum
RVSP Right ventricular systolic pressure
S.C. Subcutaneous
SA sinoatrial/Signal-averaged
SAA Septal alcohol ablation
SADS Sudden arrhythmic death syndrome
SAM Systolic anterior motion
SAMe-TT2R2 Sex (female), Age (<60 years), Medical history, Treatment, Tobacco use,
Race (non Caucasian)
SAN Sinoatrial node
SaO2 Saturated oxygen
SAPT Single antiplatelet therapy
SAR Specific absorption rate
SAS Sleep apnea syndrome
SAVOR-TIMI Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with
Diabetes Mellitus–Thrombolysis in Myocardial Infarction
SAVR Surgical aortic valve replacement
SB Sinus bradycardia
SBP Systolic blood pressure
SCA Sudden cardiac arrest
SCAD Stable coronary artery disease/Spontaneous coronary artery dissection
SCD Sudden cardiac death
SCORE Systematic Coronary Risk Evaluation/Systematic Coronary Risk Estima-
tion
SCORE2 Systemic Coronary Risk Estimation 2
SD sudden death
SDM Shared Decision Making
SFA Superficial femoral artery
SGLT Sodium-glucose co-transporter
SGLT2 Sodium glucose co-transporter 2
SHD structural heart disease
S-ICD subcutaneous ICD
SIDS Sudden infant death syndrome
SIMVA Simvastatin
SIRS Systemic inflammatory response
SLE Systemic lupus erythematosus
SMART Specific, Measurable, Achievable, Realistic and Timely
SMART- Secondary Manifestations of Arterial Disease−Reduction of Atherothrom-
REACH bosis for Continued Health
SMI Severe mental illness
SMR Secondary mitral regurgitation
SMVT sustained monomorphic ventricular tachycardia
SND Sinus node disease
SNRIs Serotonin-noradrenaline reuptake inhibitors
SNS Sympathetic nervous systems
SPAP Systolic pulmonary artery pressure/Systolic pulmonary arterial pressure
SPECT Single-photon emission computed tomography
SPERRI Shortest pre-excited RR interval during atrial fibrillation
sPESI Simplified Pulmonary Embolism Severity Index
SpO2 Saturation of peripheral oxygen/Transcutaneous oxygen saturation
SPVT sustained polymorphic VT
SQTS Short QT syndrome
SR Sinus rhythm
SSRI Selective serotonin reuptake inhibitors
SSS Sick sinus syndrome
ST ST-segment
ST-T ST-segment-T wave
STE-ACS ST-segment elevation acute coronary syndrome
STEMI ST-elevation myocardial infarction/ST-segment elevation myocardial in-
farction
STS Society of Thoracic Surgeon/Structured telephone support
STS-PROM Society of Thoracic Surgeons Predicted Risk of Mortality/Society of Tho-
racic Surgeons – patient risk of mortality
SU Sulphonylureas
SubAS Subaortic stenosis
SUDI Sudden unexplained death in infancy
SUDS Sudden unexplained death syndrome
SupraAS Supravalvular aortic stenosis
SVC Superior vena cava
SVD Structural valve deterioration
SVG Saphenous vein graft
SVi Stroke volume index
SVR Surgical ventricular reconstruction.
SVT Supraventricular tachycardia
SWISSIII Swiss Interventional Study on Silent Ischemia Type II
SYNTAX SYNergy between percutaneous coronary intervention with TAXus and
cardiac surgery
T-DM1 Trastuzumab-emtansine
T1 Type 1
T1DM Type 1/I diabetes mellitus
T2DM Type 2/II diabetes mellitus
TA Tricuspid annulus
TAA Thoracic aortic aneurysm
TAAD Thoracic aortic aneurysms and dissection
TAI Traumatic aortic injury
TAPSE Tricuspid annulus plane systolic excursion/Tricuspid annular pulmonary
systolic excursion
TASC TransAtlantic Inter-Society Consensus
TAT Triple antithrombotic therapy
TAVI Transcatheter aortic valve implantation/Transaortic valve implantation
TB Tuberculosis
TBI Toe-brachial index
TC Total cholesterol
TCM Tachycardia-induced cardiomyopathy
TCMP Tachycardiomyopathies
TcPO2 Transcutaneous oxygen pressure
TE Thromboembolism/Thrombo-embolic
TEE Transesophageal echocardiogram
TEER Transcatheter edge-to-edge repair
TEVAR Thoracic endovascular aortic repair
TF Transfemoral
TG Triglyceride
TGA Complete transposition of the great arteries/Transposition of the great ar-
teries
ThreeDE Three dimensional echocardiography
TIA Transient ischaemic attack / Transitory ischaemic attack
TIBC Total iron-binding capacity
TIME Trial of invasive versus medical therapy in elderly patients with chronic
symptomatic coronary-artery disease
TIMI Thrombolysis In Myocardial Infarction
TKI Tyrosine kinase inhibitor
TL True lumen
TNF Tumor necrosis factor
TNK-tPA Tenecteplase/Tenecteplase tissue plasminogen activator
TNNI3 Troponin I, cardiac
TNNT2 Troponin T
TOD Target organ damage
TOE Transoesophageal echocardiography/echocardiogram
TOF Tetralogy of Fallot
tPA Tissue plasminogen activator
TPM1 Tropomyosin 1 alpha chain
TPVI Transcatheter pulmonary valve implantation
TR Tricuspid regurgitation
TRAPS Tumour necrosis factor receptor-associated periodic syndrome
TRL Triglyceride-rich lipoproteins
TRV Tricuspid regurgitant velocity
TS Tricuspid stenosis / Turner syndrome
TSAT Transferrin saturation
TSH Thyroid stimulating hormone
TTE Transthoracic echocardiography
TTN Titin
TTR Time in therapeutic range/Transthyretin
TTVI Transcatheter tricuspid valve intervention
TV Tricuspid valve/Television
TVI Time-velocity integral
TVR Tricuspid valve replacement or repair
Tx Tendon xanthomata
TZD Thiazolidinedione
UA Unstable angina
UEAD Upper-extremity artery disease
UFH Unfractionated heparin
UHF Ultrafractionated heparin
UK United Kingdom
UKGRIS UK GRACE Risk Score Intervention Study
ULN Upper limit of normal
US United States
USA United States of America
USFDA United States Food and Drug Administration
UVH Univentricular heart
V/Q Scan ventilation–perfusion scintigraphy
VA Vertebral artery/Ventricular arrhythmia
VAD Ventricular assist device
VATS video-assisted thoracic surgery.
VEGF Vascular endothelial growth factor
VEGFi vascular endothelial growth factor inhibitor
VERDICT Very EaRly vs Deferred Invasive evaluation using Computerized Tomog-
raphy
VF Ventricular fibrillation
VHD Valvular heart disease
VKA vitamin K antagonist
VKAs Vitamin K antagonists
VKORC1 vitamin K epoxide reductase complex 1.
VL Very low risk
VLDL Very low-density lipoprotein
Vmax Maximum Doppler velocity/Peak transvalvular velocity
VO2 Oxygen consumption
VO2max Maximum oxygen consumption
VO2peak Peak oxygen onsumption
VPBs Ventricular premature beats
vs Versus
VSD Ventricular septal defect
VT Ventricular tachycardia
VTE Venous thromboembolism
VV Interventricular
VVI Ventricular inhibited pacing
WBC White blood cells
WCD Wearable cardioverter defibrillator
WHF World Heart Federation
WHO World Health Organization
WHO-FC World Health Organization functional class
WIfI Wound, Ischaemia, and foot Infection
WPW Wolff-Parkinson-White
WU Wood units
Y yes
ΔPm Mean pressure gradient

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ESC Pocket Guidelines

Task Force Members:

ESC subspecialty communities having participated in the development of this document:

non-cardiac surgery (European Heart Journal; 2022 - doi: 10.1093/eurheartj/ehac270).

Table of ESC Classes of recommendations and levels of evidence

Definition Wording to use

Class I Evidence and/or general agreement that a given treatment or Is recommended

Table 2 Levels of evidence

For interactivity see here

Recommendations for all patients scheduled for non-cardiac surgery

Recommendations for preoperative assessment in patients with previously unknown mur-

bIf BNP/NT-proBNP testing is not available, TTE should be considered.

Recommendations for patient information

Recommendations for pre-operative assessment of frailty and functional capacity

Recommendation for pre-operative electrocardiography

Recommendations for pre-operative risk assessment - biomarkers

bSee section 4.2 of the guidelines.

c≥125 pg/mL/35 pg/mL.

CV risk factors and lifestyle interventions

Recommendations for pharmacological treatment

the RCRI score.

dose, and should be continued post-operatively.

cFor dosing, please see Figure 6.

For interactivity see here

MI, myocardial infarction; N, no; PCI, percutaneous coronary intervention; Y, yes.

high-risk patients and within 12 months in ACS/high-risk patients

dClass IIa LoE B.

fClass III LoE B.

gClass IIb LoE B.

hClass IIa LoE B.

kg/min; if creatinine clearance is <50 mL/min, adjust to 1.0 µg/kg/min.

and a maximum of 7 days.

de.g. >3 months after stroke/VTE.

eFor NOAC management during NCS, see Figure 8 and Figure 9.

For interactivity see here

NCS, non-cardiac surgery; NOAC, non-vitamin K antagonist oral anticoagulant.

ication), the NOAC should be paused 12-24 h earlier.

Pre-operative anaemia—diagnosis and treatment

Recommendations for intra- and post-operative complications associated with anaemia

cICA ± PCI/CABG on a case-by-case basis according to the Heart Team.

For interactivity see here

mended for aortic stenosis per se.

bHigh-sensitivity cardiac troponin T/I, and/or BNP/ N-terminal pro-BNP.

CIED, cardiac implantable electronic device.

Peri-operative myocardial infarction/injury

bOr other Type 2 MI trigger such as hypoxaemia, tachycardia, hypertension.

cDual antiplatelet therapy after coronary stenting.

dPossibly in combination with dabigatran 110 mg b.i.d.

For interactivity see here

loading with digoxin is preferred to avoid hypotension.

For interactivity see here

(N)OAC (Non-vitamin K antagonist) oral anticoagulant

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