Dr Danielle Menosi Gualandro and Dr Christian Puelacher (University Hospital Basel, Basel, Switzerland) share key insights on the updated 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing NCS.2,9 They highlight important updates to the guidelines relating to biomarker measurements, risk stratification prior to NCS, detection of PMI, as well as the impact and implementation of active screening for PMI in clinical practice.
1. Risk stratification
Dr Puelacher describes who should receive risk stratification prior to NCS as defined in the new ESC Guidelines. This is based on i) patient-related risk factors, including age and the presence of cardiovascular risk factors, or established cardiovascular disease, ii) surgery risk and iii) urgency of the surgery, with risk stratification only recommended for elective surgery.9 Dr Puelacher also outlines what variables should be included in the risk stratification processes prior to surgery, including accurate history, clinical examination, standard laboratory tests, and depending on the risk parameters above, ECG, biomarkers (such as high-sensitivity cardiac troponin and NT-proBNP) and functional capacity.
2. Importance of PMI screening
PMI is a common complication after NCS and is associated with an increased risk of adverse events and mortality.7,8,10 PMI is often unrecognised in routine clinical practice due to the presence of analgesia after surgery, which leads to an absence of the common symptoms of ischaemia.3,7,8,10,11 Importantly, the mortality rate associated with asymptomatic PMI is comparable to symptomatic PMI.7,8 Dr Gualandro and Dr Puelacher discuss the importance of PMI screening ahead of surgery as well as the next steps following initial screening.
3. Differential diagnosis and systematic work-up of PMI
PMI is not a homogeneous disease but rather a cluster of symptoms caused by a variety of aetiologies and clinical phenotypes.6,8-10,12-14 Aetiologies underlying PMI can be cardiac (Type I or Type II myocardial infarction, tachyarrhythmia, and acute heart failure) or non-cardiac (severe sepsis, pulmonary embolism, and stroke). Rates of major adverse cardiac events and mortality differ between the different PMI phenotypes at 30 days and 1-year post-surgery but all patients with PMI are at increased risk of worse outcomes irrespective of phenotype.6,15 Dr Gualandro and Dr Puelacher underline the importance and describe the key steps of a systematic diagnostic work-up (as recommended by the 2022 ESC Guidelines) to identify the underlying aetiology and select the most appropriate therapy to treat the cause of PMI.9
4. Implementation of PMI screening and impact on clinical practice
Since PMI is often undiagnosed but linked to a higher risk of adverse outcomes,6,16 inclusion of recommendations for active PMI screening in the 2022 ESC guidelines are aimed to improve the perioperative care for patients undergoing NCS.9 Dr Gualandro and Dr Puelacher highlight that implementation of these guidelines into routine clinical practice requires multidisciplinary collaboration between team members from anesthesiology, cardiology, and surgery, as well as implementation of workflows across the hospital. They describe the PMI workflow that has been established at their hospital, describing the details of when blood samples are taken, as well as when and how cardiologists are involved in PMI screening.
5. Unmet medical needs
There are several unmet medical needs associated with the perioperative care of patients undergoing NCS. First, the implementation of PMI screening into clinical practice can prove challenging and is not achieved at some hospitals. A second concern is bleeding risk, therefore it is important that the type of surgery being performed and bleeding risk of the patient are taken into account when pharmacological treatments are administered. Dr Puelacher and Dr Gualandro discuss these issues, as well as the importance of developing strategies to improve short- and long-term survival in these patients.