Eur J Anaesthesiol 2023; 40:385–386
EDITORIAL
Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4
Implementation of 2022 ESC guidelines for cardiovascular
XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/18/2024
assessment before non-cardiac surgery
Major concerns to meet in the near future!
mi Schweizer, Matthias Jacquet-Lagreze and Jean-Luc Fellahi
Re
European Journal of Anaesthesiology 2023, 40:385–386
We read with a great interest the recent updated version
of the ESC guidelines on cardiovascular assessment
and management of patients undergoing non-cardiac
surgery.1 Significant changes have been made when
compared with the previous recommendations published
in 2014, and some of those new recommendations
clearly ask questions of anaesthesiologists regarding
both feasibility and clinical ramifications. Moreover,
those new recommendations were endorsed in-extenso
by the ESAIC. Consequently, we wondered how far
current practice in our teaching university hospital now
deviates from them, and how long it might take to
implement them on a daily basis across the whole anaes-
thesiology team. Especially noteworthy, inter alia,
were the pivotal recommendations on the use of preop-
erative resting transthoracic echocardiography (TTE),
and assays of pre and postoperative cardiac biomarkers.
These have been markedly reinforced in the 2022
version1 and have the potential for huge modifications
of healthcare providers’ practice and a major impact on
hospital service organisation.
In consequence, we performed a 1-day retrospective,
single-centre cohort study, including all adult patients
scheduled for a non-cardiac surgical procedure that re-
quired the presence of at least one member of the
anaesthesiology team. Obstetric and cardiological proce-
dures were not included. The main goal of the study was
to examine the ratio of actually performed tests versus
those recommended regarding both preoperative TTE
and NT-proBNP/BNP assays. Two hundred and fifty
adult patients met the inclusion criteria. Among them,
72% (179/250) had cardiovascular risk factors, including
age at least 65 years, and 34% (85/250) had known
From the Service d’Anesth
esie-R
eanimation, Hôpital Louis Pradel, Hospices Civils de Lyon (RS, MJ-L, J-LF) and Laboratoire CarMeN, Inserm UMR 1060, Universit
Bernard Lyon 1, Lyon, France (MJ-L, J-LF)
Correspondence to R emi Schweizer, MD, Hopital Cardio-vasculaire et Pneumologique Louis Pradel, Bron 69500 France
E-mail: remi.schweizer@chu-lyon.fr
0265-0215 Copyright ß 2023 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.
Copyright © 2023 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.
cardiovascular disease. Surgical procedures were elective
(50%), time-sensitive (31%) or urgent/immediate (19%),
and classified as high-risk (2%), intermediate-risk (22%),
low-risk (24%) or unclassified (52%). According to the
new guidelines, preoperative resting TTE was recom-
mended for 17% (43/250) of these patients, predominant-
ly with a IIb class recommendation (41/43). The
performed : recommended ratio on preoperative TTE
was 0.21 (9/43). Preoperative NT-pro-BNP/BNP assays
were recommended in 24% (61/250) of patients, with a
I class recommendation for 26 patients and a IIa class
recommendation for 35 patients. The performed :
recommended ratio on preoperative NT-proBNP/BNP
was 0 (0/61).
These results clearly show the dramatic gap between the
most recent guidelines and routine practice in our tertiary
centre. There are three major concerns which will result
from guideline implementation in the near future. First,
it seems obvious that the surgical risk estimate according
to the type of surgery or intervention has only been
slightly modified compared with the previous classifica-
tion,2 and the method proposed to discriminate between
high-risk and intermediate-to-low risk is not appropriate.
Indeed, more than 50% of our surgical procedures were
unclassified by the clinicians, mainly because numerous
operative procedures are not listed. Thus, upper limb
orthopaedic surgery, colectomy or digestive endoscopy
could not be easily classified by practitioners as they do
not specifically appear in the published table. Moreover,
high surgical risk is variably estimated across the quality
indicators in the same guidelines, adding to the confusion
with this classification.3
Second, preoperative resting TTE has gained an increas-
ing role despite lack of evidence that it reduces postop-
erative major adverse cardiovascular events and
mortality.4,5 Nevertheless this leads to a significant
e Claude
DOI:10.1097/EJA.0000000000001835
 386 Schweizer et al.
proportion of patients in our cohort that ‘should’ have
undergone TTE according to the guidelines. This pro-
portion of patients would represent nearly one-third of
the daily total TTE throughput in our echocardiography
lab. Moreover, the number of ‘required’ preoperative
TTE was probably underestimated since more than half
Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4
of the surgical procedures were unclassified. Significant-
ly, the role of resting TTE was somewhat limited in
XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 02/18/2024
the Canadian Cardiovascular Society guidelines on
perioperative cardiac risk assessment and management
for patients who undergo non-cardiac surgery, published
only a couple of years ago.6 Anyway, both a re-organisa-
tion of the echo lab and focused cardiac ultrasound exams
performed by trained specialists other than cardiologists
would be necessary both to meet the new ESC guidelines
(class IIb, level B)1 and to avoid delaying surgery.
Third, with the significantly upgraded recommendations
in the 2022 version regarding cardiac biomarkers, while in
accordance with the Canadian guidelines,6 the liberal use
of perioperative biomarkers, strongly demands a thor-
ough explanation of what the proposed virtuous circle of
this use of perioperative cardiac biomarkers is. Indeed,
the worldwide cost of such a liberal use of biomarkers
should be counterbalanced by a credible medical decision
for a given patient (to do or not to do), and by a sustained
clinical benefit in routine practice.7 Some differences in
the methodological approach, also taking into account
practical and clinical aspects of perioperative cardiac
risk assessment, could lead to potentially different
Eur J Anaesthesiol 2023; 40:385–386
Copyright © 2023 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.
recommendations in the upcoming focused guidelines
of the ESAIC on perioperative use of cardiac biomarkers.
Acknowledgements relating to this article
Assistance with the Editorial: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
The manuscript was handled by Michelle S Chew.
References
1 Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on
cardiovascular assessment and management of patients undergoing
noncardiac surgery. Eur Heart J 2022; 43:3826–3924.
2 Glance LG, Lustik SJ, Hannan EL, et al. The surgical mortality probability
model: derivation and validation of a simple risk prediction rule for noncardiac
surgery. Ann Surg 2012; 255:696–702.
3 Gencer B, Gale CP, Aktaa S, et al. European Society of Cardiology quality
indicators for the cardiovascular preoperative assessment and management
of patients considered for noncardiac surgery. Developed in collaboration
with the European Society of Anaesthesiology & Intensive Care. Eur Heart J
Qual Care Clin Outcomes 2022;qcac057; doi: 10.1093/ehjqcco/qcac057.
4 Lurati Buse GAL, Puelacher C, Gualandro DM, et al. Adherence to the
European Society of Cardiology/European Society of Anaesthesiology
recommendations on preoperative cardiac testing and association with
positive results and cardiac events: a cohort study. Br J Anaesth 2021;
127:376–385.
5 Wijeysundera DN, Beattie WS, Karkouti K, et al. Association of
echocardiography before major elective noncardiac surgery with
postoperative survival and length of hospital stay: population based cohort
study. BMJ 2011; 342:d3695.
6 Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society
guidelines on perioperative cardiac risk assessment and management for
patients who undergo noncardiac surgery. Can J Cardiol 2017; 33:17–32.
7 Fellahi JL, Piriou V, Longrois D. Cardiac biomarkers in perioperative risk
stratification. Ann Fr Anesth Reanim 2011; 30:126–140.