European guidelines for noncardiac surgery

The European Society of Cardiology has published its first guidelines on the management of cardiac risk in non-cardiac surgery. The guidelines are similar to existing US guidelines published in 2007, with the major difference centering on the recommendation for beta blockers. Presenting the guidelines at ESC 2009, Dr Don Poldermans (Erasmus Medical Centre, Rotterdam) said the guidelines recommended a practical, stepwise evaluation of the patient, integrating cardiac risk factors and test results with the estimated stress of the planned surgical procedure. They recommend preoperative assessment of clinical risk factors, such as heart failure, previous myocardial infarction, and diabetes, to stratify patients according to risk of cardiac events. However, the use of additional cardiac testing, such as echocardiography or exercise testing, is only recommended for patients with multiple risk factors scheduled for high risk surgery. Specific recommendations address the titration of beta blockers. The new guidance recommends that a low dose of beta blocker be started prior to surgery, with the dose titrated to achieve a heart rate of between 60 and 70 beats per minute. “The key thing in these patients is to reduce heart rate, not to block heart-rate response. If, for instance, during surgery you have a bleed, then you want the heart to pump up to maintain blood pressure, so if we overdo it, we take back the beta blocker,” Polderman said at a press conference. The guidelines also recommend the use of statins with a long half-life or extended-release formations to bridge the period immediately after surgery when oral intake is not feasible. Aspirin therapy should be continued, and only stopped in those in which haemostasis is difficult to control during surgery. Commenting on the guidelines, Sidney Smith (University of North Carolina, Chapel Hill) said he was impressed the new guidelines made an effort to reduce the amount of pre-operative testing....