South African cardiovascular risk stratification guideline for non-cardiac surgery

Executive summary The South African (SA) guidelines for cardiac patients for non-cardiac surgery were developed to address the need for cardiac risk assessment and risk stratification for elective non-cardiac surgical patients in SA, and more broadly in Africa.The guidelines were developed by updating the Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Non-cardiac Surgery, with a search of literature from African countries and recent publications. The updated proposed guidelines were then evaluated in a Delphi consensus process by SA anaesthesia and vascular surgical experts. The recommendations in these guidelines are:1. We suggest that elective non-cardiac surgical patients who are 45 years and older with either a history of coronary artery disease, congestive cardiac failure, stroke or transient ischaemic attack, or vascular surgical patients 18 years or older with peripheral vascular disease require further preoperative risk stratification as their predicted 30-day major adverse cardiac event (MACE) risk exceeds 5% (conditional recommendation: moderate-quality evidence).2. We do not recommend routine non-invasive testing for cardiovascular risk stratification prior to elective non-cardiac surgery in adults (strong recommendation: low-to-moderate-quality evidence).3. We recommend that elective non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease should have preoperative natriuretic peptide (NP) screening (strong recommendation: high-quality evidence).4. We recommend daily postoperative troponin measurements for 48 - 72 hours for non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease, i.e. (i) a baseline risk >5% for MACE 30 days after elective surgery (if no preoperative NP screening), or (ii) an elevated B-type natriuretic peptide (BNP)/N-terminal-prohormone B-type natriuretic peptide (NT-proBNP) measurement before elective surgery (defined as BNP >99 pg/mL or a NT-proBNP >300 pg/mL) (conditional recommendation: moderate-quality evidence).Additional recommendations are given for the management of myocardial injury after non-cardiac surgery (MINS) and medications for comorbidities.

The coronary CT angiography vision protocol: a prospective observational imaging cohort study in patients undergoing non-cardiac surgery

INTRODUCTION

At present, physicians have a limited ability to predict major cardiovascular complications after non-cardiac surgery and little is known about the anatomy of coronary arteries associated with perioperative myocardial infarction. We have initiated the Coronary CT Angiography (CTA) VISION Study to (1) establish the predictive value of coronary CTA for perioperative myocardial infarction and death and (2) describe the coronary anatomy of patients that have a perioperative myocardial infarction.

METHODS AND ANALYSIS

The Coronary CTA VISION Study is prospective observational study. Preoperative coronary CTA will be performed in 1000-1500 patients with a history of vascular disease or at least three cardiovascular risk factors who are undergoing major elective non-cardiac surgery. Serial troponin will be measured 6-12 h after surgery and daily for the first 3 days after surgery. Major vascular outcomes at 30 days and 1 year after surgery will be independently adjudicated.

ETHICS AND DISSEMINATION

Coronary CTA results in a measurable radiation exposure that is similar to a nuclear perfusion scan (10-12 mSV). Treating physicians will be blinded to the CTA results until 30 days after surgery in order to provide the most unbiased assessment of its prognostic capabilities. The only exception will be the presence of a left main stenosis >50%. This approach is supported by best available current evidence that, excluding left main disease, prophylatic revascularisation prior to non-cardiac surgery does not improve outcomes. An external safety and monitoring committee is overseeing the study and will review outcome data at regular intervals. Publications describing the results of the study will be submitted to major peer-reviewed journals and presented at international medical conferences.