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Published in: Chinese Journal of Cardiovascular Diseases, 2023, 51(10) : 1043-1055
Authors: Cardiovascular Disease Branch of the Chinese Medical Association, Editorial Board of the Chinese Journal of Cardiovascular Diseases
Corresponding authors: Chen Jiyan, Yuan Zuyi
Abstract
A large number of patients undergoing non-cardiac surgery have coexisting cardiovascular diseases or risk factors for cardiovascular diseases. These patients require cardiovascular event risk assessment during the perioperative period. Patients with established cardiovascular diseases also need evaluation of the timing of surgery and adjustment of current cardiovascular medications to minimize the risk of perioperative cardiovascular events. Furthermore, perioperative management of cardiovascular diseases in non-cardiac surgery should avoid excessive examinations that increase medical costs and avoid unnecessary delays in surgery that would adversely affect patient prognosis. In recent years, international clinical guidelines/expert consensus for perioperative cardiovascular disease management in non-cardiac surgery have been updated, but relevant guidelines or consensus are still lacking in China. This consensus is based on current evidence-based medicine evidence, combined with domestic and international guidelines and the current status of domestic medical resources, focusing on addressing the above issues and providing practical diagnosis and management plans for cardiology specialists and surgeons.
Main Text
Every year, 4% of the global population undergoes surgical procedures, among whom approximately one-third have cardiovascular disease-related risk factors［1］. Among patients aged 45 and above undergoing non-cardiac surgery (NCS), 45% have multiple cardiovascular risk factors such as hypertension and dyslipidemia, and nearly 25% have atherosclerotic cardiovascular disease［2］. In recent years, Europe［1,3,4］ and North America［5,6］ have successively issued guidelines and consensus on the management of cardiovascular diseases during the perioperative period of NCS. In addition, the prevalence of cardiovascular disease in China is approximately 330 million［7,8］, and many of these patients require NCS. How to standardize perioperative evaluation and management for these patients is an urgent problem to be solved.
Although extensive clinical trials and prospective observational studies in recent decades have improved our understanding of perioperative cardiac complications, cardiac complications after NCS remain a major public health problem. Currently, how to correctly assess and prevent perioperative cardiovascular risk in patients undergoing NCS remains a challenge for clinicians. To address this clinical issue, the Atherosclerosis and Coronary Heart Disease Group of the Cardiovascular Disease Branch of the Chinese Medical Association, with reference to domestic and international guidelines, combined with recent evidence-based medicine evidence and expert experience, formulated this consensus. It systematically summarizes risk stratification, scoring systems, examination methods, medication, and invasive treatments for perioperative cardiovascular risk during NCS and provides recommendations aiming to guide clinicians in individualized and standardized cardiovascular evaluation and management during the perioperative period. This consensus uses “++”, “+/±” and “-” to represent different recommendation categories and types of evidence, which are not equivalent to the recommendation classes (I, II, III) and evidence levels (A, B, C) used in guidelines (Table 1).
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Preoperative Cardiovascular Event Risk Assessment for NCS
1. Impact of Surgery Type on Cardiovascular Event Risk
The incidence of major adverse cardiovascular events (MACE) during the perioperative period is closely related to the type of surgery［9］. NCS with a MACE incidence <1% is considered low-risk surgery, while open or hemodynamically significant surgeries are regarded as high-risk surgeries, with a MACE incidence >5% (Table 2)［1,5］. Furthermore, according to the timing of surgery, NCS can be divided into emergency surgery, urgent surgery, and elective surgery. Emergency surgery needs to be performed as soon as possible to save lives or organ function and should not be delayed; urgent surgery, if delayed, may significantly affect patient prognosis and organ function, such as excision of malignant tumors or carotid surgery in patients at high risk of stroke. However, the impact of timing on prognosis varies depending on the underlying disease; elective surgeries can be safely postponed (Table 3)［3］.
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2. Assessment of Perioperative Cardiovascular Adverse Event Risk
Risk assessment of MACE during the perioperative period begins with identifying whether the patient has a history of cardiovascular disease, cardiovascular risk factors, and abnormal physical signs of the cardiovascular system. The patient’s functional capacity is also closely related to MACE risk. If a patient is unable to perform physical activities with >4 metabolic equivalents of task (METs), such as walking uphill or climbing more than two flights of stairs, for any reason, their perioperative MACE risk is increased［10,11］.
Risk scoring systems are important tools to assist in assessing MACE risk. The Revised Cardiac Risk Index (RCRI) is a simple and easy-to-use scoring tool (Table 4) that assesses MACE risk based on total scores［6］. Other more complex scoring systems, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and the American University of Beirut (AUB)-HAS2 cardiovascular risk index, can provide a more comprehensive assessment［3］.
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It should be noted that RCRI is mainly used to assess whether perioperative MACE risk in non-elderly patients without previous cardiovascular disease undergoing NCS is elevated. According to recent Chinese population studies, RCRI has limitations in predicting cardiovascular events in high-risk patients, especially those with established cardiovascular diseases and the elderly［12,13,14］. Single-center studies conducted recently in China proposed the HASBLAD score, which predicts cardiovascular risk more accurately in the Chinese population than RCRI［12］. Therefore, it is not recommended to rely solely on a specific scoring system for perioperative cardiovascular risk assessment; comprehensive clinical evaluation is necessary.
3. Preoperative Cardiac Biomarker Testing
B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are commonly used serum markers for heart failure. Preoperative BNP ≥92 ng/L or NT-proBNP ≥300 ng/L indicates increased 30-day postoperative mortality or myocardial infarction risk［15］. Cardiac troponins T and I are commonly used to diagnose myocardial infarction or injury, and elevated baseline troponin levels are associated with perioperative myocardial infarction and increased long-term mortality［16］. Myocardial infarction is a common complication after NCS; thus, in patients at high cardiovascular risk, preoperative troponin testing should be completed and monitored postoperatively for elevation to diagnose myocardial infarction promptly［17］.
Cardiac biomarker testing is a common tool for cardiovascular risk stratification. Based on existing evidence, this consensus recommends cardiac biomarker testing in patients at high cardiovascular risk during the perioperative period; specific recommendations are shown in Table 5.
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4. Preoperative Cardiovascular Ancillary Tests
Preoperative cardiovascular ancillary tests aim to confirm the presence of myocardial ischemia, cardiac structural and functional abnormalities, arrhythmias, and other cardiovascular diseases. Commonly used tests include electrocardiogram (ECG), transthoracic echocardiogram (TTE), Holter ECG, ambulatory blood pressure monitoring, exercise ECG stress test, and coronary computed tomography angiography (CTA).
ECG is easy to perform and can screen for arrhythmias and myocardial ischemia; it is routinely used preoperatively in patients at risk for MACE. Echocardiography mainly evaluates cardiac function and structure and should be performed preoperatively if cardiovascular disease is suspected. Exercise ECG stress tests and coronary CTA are primarily used for myocardial ischemia screening. Cardiopulmonary exercise testing assesses respiratory and circulatory function levels to assist in perioperative MACE risk assessment.
Coronary angiography is an invasive test involving anticoagulation and antiplatelet drugs. Excessive preoperative testing may delay surgery. Coronary angiography before NCS is only necessary when judged by a cardiovascular specialist to have a high likelihood that the patient requires percutaneous coronary intervention (PCI) before surgery［1］. Indications for PCI are detailed in the “Preoperative Coronary Intervention” section. Recommendations for ancillary cardiovascular tests during perioperative evaluation for NCS are shown in Table 6.
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Perioperative Cardiovascular Medications in NCS
1. Use of Perioperative Antiplatelet Drugs
With the increasing incidence of cardiovascular diseases, more patients require long-term antiplatelet therapy, especially those requiring dual antiplatelet therapy (DAPT) after PCI for a certain duration. These patients need assessment of bleeding and thrombosis risk before surgery or invasive procedures to select optimal management strategies. The type of surgery is closely related to bleeding risk and can be classified accordingly (Table 7)［3］. In cases of emergency surgery or major perioperative bleeding in these patients, transfusion of platelet concentrates or hemostatic agents (such as antifibrinolytics, recombinant coagulation factors) may be administered. For bridging with intravenous antiplatelet drugs, tirofiban should be discontinued 6 hours before surgery, and cangrelor 1 to 6 hours before surgery. This expert consensus provides recommendations on DAPT duration and perioperative antiplatelet drug adjustment in post-PCI patients according to current guidelines and evidence［18,19,20,21,22］. Specific recommendations and pathways are detailed in Table 8 and Figure 1.
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2. Use of Perioperative Anticoagulants
Patients undergoing heart valve replacement, with atrial fibrillation, and venous thromboembolism (VTE) require long-term oral anticoagulants, increasing bleeding risk. During NCS, perioperative medication adjustment is necessary; specific adjustment processes are shown in Figure 2. Details regarding warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) use refer to “Chinese Expert Consensus on Warfarin Anticoagulation Therapy” and “Chinese Expert Recommendations on New Oral Anticoagulants for Non-Valvular Atrial Fibrillation”［23,24］.
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If preoperative withdrawal time for anticoagulants is insufficient, coagulation function should be tested. Patients on warfarin with an international normalized ratio (INR) <1.5 can generally undergo surgery safely; if INR >1.5, small doses (1–2 mg) of vitamin K can be administered to rapidly reduce INR. For emergency surgery with significantly elevated INR, fresh frozen plasma (5–8 ml/kg) or prothrombin complex concentrate can be given.
3. Use of Perioperative β-Blockers
Evidence indicates that preoperative use of β-blockers may reduce the incidence of perioperative nonfatal myocardial infarction and atrial fibrillation but does not reduce mortality［25,26,27］. Short-term, high-dose preoperative β-blocker initiation may even increase all-cause mortality and postoperative stroke risk［28,29,30］. Therefore, routine preoperative β-blocker use to improve NCS outcomes is not recommended［31］.
4. Use of Perioperative Statins
Perioperative statin use can reduce all-cause mortality, cardiovascular mortality, and cardiovascular event risk in NCS［3,5,32,33］. Patients already on statins should continue during the perioperative period. Patients with indications for statins but not yet using them may begin as early as possible. The cumulative statin dose is key to its preventive effect; prophylactic use is best started more than 2 weeks preoperatively［1］, while loading dose within 1 day preoperatively may be ineffective［34］.
5. Use of Perioperative Angiotensin-Converting Enzyme Inhibitors (ACEI)/Angiotensin Receptor Blockers (ARB)/Angiotensin Receptor Neprilysin Inhibitors (ARNI)
Patients with heart failure and hypertension may require long-term ACEI/ARB/ARNI therapy. Regarding whether to discontinue these drugs preoperatively in NCS patients, clinical study conclusions are inconsistent. Based on current evidence, the consensus recommends withholding ACEI/ARB/ARNI within 24 hours before NCS in patients on long-term therapy; medication can be resumed on postoperative day 2 if hemodynamics are stable［6,35,36］. For stable heart failure patients with reduced left ventricular ejection fraction <40% not yet on these drugs, initiating them one week before surgery may be considered, monitoring blood pressure tolerance.
6. Use of Other Perioperative Cardiovascular Drugs
Patients on long-term calcium channel blockers (CCB) may continue them perioperatively; routine addition of CCB solely for perioperative cardiovascular event prevention is not recommended.
Patients on diuretics for hypertension or heart failure can continue perioperatively and stop one day before surgery, with close monitoring of electrolytes, blood pressure, and ECG.
Studies show α2 receptor blockers do not reduce mortality or nonfatal myocardial infarction in overall NCS populations and increase risks of hypotension and nonfatal cardiac arrest［37］; thus, α2 receptor blockers should be avoided perioperatively in NCS patients.
Recommendations for use of β-blockers, statins, and ACEI/ARB/ARNI during perioperative period are detailed in Table 9.
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7. Preoperative Coronary Intervention
Routine DAPT is required post-PCI. Performing PCI before NCS increases perioperative bleeding and thrombosis risk, and there is no evidence supporting routine preoperative PCI for coronary lesions before NCS［38］; unnecessary preoperative PCI should be avoided. If elective NCS can be safely delayed until after completion of DAPT, preoperative PCI can prevent cardiac ischemia-related perioperative complications.
- Preventive Revascularization for Stable Coronary Artery Disease: For stable coronary artery disease patients with obstructive coronary artery lesions, including asymptomatic or stable angina cases, prophylactic PCI or coronary artery bypass grafting (CABG) before surgery is not recommended. If patients plan elective medium- to high-risk surgery and have left main disease without considering simultaneous CABG, preoperative revascularization may be considered［5］. Patients with a positive cardiac stress test indicating large ischemic territories or unexplained left ventricular dysfunction scheduled for elective high-risk surgery may undergo coronary angiography preoperatively to evaluate the need for preventive revascularization. Other than these scenarios, routine coronary angiography and revascularization solely to reduce surgical risk are not recommended［1,3］. Related recommendations are shown in Table 10.
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- Revascularization for Acute Coronary Syndrome (ACS) Patients: Patients with ACS scheduled for elective NCS should undergo PCI before surgery to improve survival［39］. Those requiring emergency NCS with ACS have high perioperative MACE risk and complex conditions; multidisciplinary team assessment weighing risks and benefits is recommended.
Perioperative Decision Making in Special Populations
1. Emergency Surgery Patients
Compared with elective surgery, emergency surgery performed within 24 hours shows significantly increased 30-day mortality, unplanned reoperations, and rehospitalization［40］. Urgency should be first assessed before NCS［3］. For patients requiring emergency surgery to save life, surgery should not be delayed for cardiovascular risk assessment or management［6］; cardiovascular consultation is advised when feasible to provide perioperative cardiovascular disease management and event prevention guidance［1］. For surgeries needed within 6–24 hours, preoperative cardiovascular risk evaluation is recommended only if history or physical examination suggests acute heart failure, ACS, severe obstructive heart disease (e.g., severe valvular stenosis, left ventricular outflow tract obstruction), or severe pulmonary hypertension［1,6］. For patients with unstable cardiovascular disease, multidisciplinary collaboration should prioritize surgery and consider hemodynamic monitoring during perioperative period［41］.
2. Elderly Population
Advanced age is a risk factor for various cardiovascular diseases; elderly have higher cardiovascular risk than younger adults, necessitating more rigorous preoperative screening. Recommendations for preoperative cardiac biomarker testing in patients aged 65 and older are detailed in Table 5. Postoperative cardiac biomarker testing helps timely identification of perioperative myocardial infarction and injury and aids cardiovascular risk assessment［3,42］. Patients over 65 undergoing medium- to high-risk surgery should routinely receive preoperative ECG screening［1,3］; other ancillary test recommendations are shown in Table 6.
3. Pregnant Women
For pregnant women planning NCS complicated by cardiovascular disease or risk, cardiovascular disease management and pregnancy risk assessment refer to the “Expert Consensus on Diagnosis and Treatment of Pregnancy Combined with Heart Disease (2016)”［43］. Complete assessment should include evaluation of suitability for continuing pregnancy, timing and method of termination if applicable, and peripartum management. Since heart failure often occurs during pregnancy, routine perioperative monitoring of BNP/NT-proBNP is recommended［44,45］. Routine pre- and postoperative ECG is also advised［46］, and TTE may be considered to evaluate cardiac function and structure.
4. Patients Recently Undergoing Coronary Revascularization
Early NCS after coronary revascularization significantly increases perioperative major cardiovascular and cerebrovascular event risk, with shorter interval correlating with higher risk［47］. Where possible, elective surgery should be postponed to reduce thrombosis risk from DAPT cessation［3,48,49,50］; related recommendations are in Table 10. The clinical use of drug-coated balloon angioplasty is increasing; patients require at least one month of DAPT post-procedure.
5. Chronic Heart Failure Patients
Patients with chronic heart failure planned for NCS should maintain preexisting treatment regimens as much as possible. Newly diagnosed heart failure patients with reduced ejection fraction should have elective surgery postponed until medications are stabilized and effective［51］. Rapid initiation of high-dose β-blockers and/or ACEI before surgery without sufficient titration is not recommended［30］. Volume management is critical prior to elective surgery in heart failure patients to avoid heart failure exacerbation or organ hypoperfusion. Perioperative medication use is detailed in the “Perioperative Cardiovascular Medications in NCS” section.
If postoperative symptoms or signs suggest heart failure, ECG, echocardiography, and necessary imaging should be performed, and cardiac biomarkers including BNP/NT-proBNP/troponin monitored. Attention to volume status and fluid balance is essential. Established heart failure should be managed similarly to non-surgical patients. Postoperative discharge planning requires caution and close follow-up to prevent recurrent heart failure［52,53］.
6. Hypertensive Patients
Clinicians should inquire about and monitor blood pressure in patients planned for NCS to establish preoperative blood pressure control targets and, if possible, further screen for hypertensive target organ damage［54］.
Most patients should maintain blood pressure below 140/90 mmHg perioperatively (1 mmHg=0.133 kPa); patients over 60 without diabetes or chronic kidney disease can aim for systolic pressure below 150 mmHg. Surgery should be postponed if blood pressure remains above 180/110 mmHg upon entering the surgical suite［55］.
Perioperative medication use is detailed in the “Perioperative Cardiovascular Medications in NCS” section.
7. Patients with Arrhythmias
Patients with a history of arrhythmias on long-term medication should continue their antiarrhythmic drugs perioperatively. Patients with permanent pacemakers may have pacemaker settings adjusted preoperatively. Routine antiarrhythmic drug therapy or prophylactic radiofrequency ablation is not recommended perioperatively for isolated supraventricular premature beats, ventricular premature beats, or non-sustained tachycardias.
Patients with atrial fibrillation or ventricular tachycardia should undergo preoperative echocardiographic assessment of cardiac structure and function［1］.When perioperative tachycardia causing hemodynamic instability occurs, electrical cardioversion or defibrillation should be performed. If it occurs before NCS (non-cardiac surgery), potential causes of arrhythmia (such as coronary ischemia, electrolyte disturbances) should be investigated, and multidisciplinary consultation should determine whether to postpone elective surgery.
For patients with bradyarrhythmias, the indications for temporary pacemaker implantation during the perioperative period are the same as those for non-surgical patients. When the indication for temporary pacemaker implantation before NCS is unclear, further tests such as ambulatory ECG can assist in the assessment. New-onset bradyarrhythmias after surgery should not prompt premature permanent pacemaker implantation.
8. Patients with Structural Heart Disease
Structural heart diseases include valvular heart disease and congenital heart disease, often detected by heart murmurs during auscultation. Patients suspected of having structural heart disease based on history and signs should undergo echocardiography preoperatively to clarify the type of cardiac structural abnormalities, quantify severity, and assess cardiac function.
The key to determine whether structural heart disease affects the timing of NCS is whether hemodynamics are significantly altered. Patients with asymptomatic mild or moderate valve regurgitation or stenosis, those not requiring corrective treatment, or those with fully corrected congenital heart disease do not need to postpone surgery. Severe structural heart disease can proceed to urgent NCS under hemodynamic monitoring, while semi-elective or elective NCS needs evaluation to decide the sequence of cardiac surgery and NCS, and the necessity of NCS.
In recent years, interventional therapy for heart valves has rapidly developed, with frequent updates to guidelines on valvular heart disease and changing treatment indications［56, 57, 58］. Patients with severe valve stenosis have a higher risk of perioperative sudden death. Those with left ventricular enlargement and impaired systolic function are prone to perioperative heart failure. Therefore, for patients with valvular heart disease requiring treatment who plan to undergo semi-elective or elective moderate/high-risk NCS, if NCS can be safely delayed until after valvular intervention or surgery, it is recommended to perform NCS post-treatment; if surgery cannot be safely postponed, intensive hemodynamic monitoring during the perioperative period should be considered. Patients with prosthetic heart valves and good valve and cardiac function do not have an increased risk during NCS. Anticoagulation management can refer to the section “Cardiovascular Medications in the Perioperative Period of NCS.” The decision-making flowchart for timing of NCS in patients with valvular heart disease is shown in Figure 3.
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Recommended perioperative decision suggestions for special populations undergoing NCS are shown in Table 11.
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Monitoring of Important Cardiovascular Events During Perioperative Period of NCS
1. Postoperative Myocardial Infarction or Myocardial Injury
Postoperative myocardial injury (PMI) is defined as an elevation of cardiac biomarkers indicating acute myocardial injury after surgery, with or without clinical symptoms, ischemic ECG changes, or imaging abnormalities. If the postoperative 24- or 48-hour troponin level is elevated above the preoperative baseline (if baseline is unavailable, the 24-hour postoperative level can serve as baseline) and exceeds the normal upper limit of the assay, PMI can be diagnosed. If accompanied by ischemic ECG changes or new regional wall motion abnormalities/reduced viable myocardium on imaging, postoperative myocardial infarction can be diagnosed［3］. Domestic clinical studies show PMI incidence reaches up to 14% in patients aged over 80 and is highly correlated with short- and long-term mortality［59］. Because most PMI occurs intraoperatively or during postoperative anesthesia/analgesia［60］ and about 90% of PMI patients lack overt clinical symptoms, it is easy to miss without active monitoring［61, 62, 63］. Therefore, patients with risk factors should have preoperative baseline troponin measurement (see Table 5) with postoperative rechecks.
PMI has multiple causes; aside from coronary ischemia, it may be caused by acute heart failure, tachyarrhythmias, sepsis, pulmonary embolism, etc. Mechanisms of postoperative myocardial infarction besides coronary occlusion include myocardial hypoperfusion induced by severe anemia or hypotension on the background of coronary stenosis. Except when acute coronary occlusion is suspected, emergency coronary intervention is not required, and treatment should focus on the primary cause. If myocardial infarction is caused by rupture of atherosclerotic plaque and thrombosis, in addition to antiplatelets and statins, consultation with cardiology about coronary intervention is necessary. ECG, echocardiography, and other tests aid in diagnosing postoperative myocardial infarction and determining the need for coronary intervention.
Stress cardiomyopathy during the perioperative period may represent a rare type of PMI. Because of lacking clear diagnostic criteria, the incidence remains unclear, but diagnosis relies heavily on typical imaging features. Typical imaging findings on echocardiography should prompt consideration of stress cardiomyopathy.
2. Perioperative Heart Failure
The risk of heart failure after NCS is highly related to preexisting conditions. Preoperative risk assessment is essential, and chronic heart failure patients should continue their usual therapy. Volume management is key to avoiding perioperative heart failure. High-risk patients for major adverse cardiovascular events (MACE) should consider goal-directed therapy (GDT) for fluid management［64, 65］. Treatment principles for acute heart failure after NCS are the same as for other heart failure patients.
3. Perioperative Venous Thromboembolism (VTE) and Pulmonary Embolism
Mortality is high among patients with perioperative VTE/pulmonary embolism during NCS, though exact incidence remains unclear［66］. For patients with unexplained perioperative myocardial injury, acute pulmonary embolism should be considered and diagnostic tests performed promptly. Once diagnosed, anticoagulation should be started early, preferably with low-molecular-weight heparin or fondaparinux. Echocardiography and hemodynamic assessment play important roles in deciding whether further treatments such as thrombolysis or pulmonary artery intervention/surgery are needed beyond anticoagulation. Subsequent oral anticoagulation therapy can be used if bleeding risk permits, with treatment duration lasting at least 3 months［67］.
4. Perioperative Atrial Fibrillation and Other Arrhythmias
Patients with cardiovascular disease or risk factors are prone to arrhythmias during NCS due to stress, medication effects, and volume or electrolyte fluctuations［5］. Routine ECG monitoring is recommended in the perioperative period for NCS patients with cardiovascular disease/risk.
Management of rapid arrhythmias during the perioperative period of NCS follows the same principles as at other times. Newly onset tachyarrhythmias with hemodynamic instability during perioperative period should be treated with electrical cardioversion, including supraventricular arrhythmias such as atrial fibrillation［3］.
Atrial fibrillation is a relatively common arrhythmia perioperatively. Recent randomized controlled trials in cardiac surgical patients showed rhythm control strategies do not confer additional clinical benefit compared to rate control［61］. During the perioperative period of NCS, heart rate should be controlled below 110 bpm in atrial fibrillation patients; medication options are the same as outside perioperative setting and can be chosen based on left ventricular systolic function, including β-blockers, digoxin, or calcium channel blockers. If ventricular rate is difficult to control or symptoms occur, pharmacologic or electrical cardioversion can be attempted, but for nonurgent cardioversion and atrial fibrillation lasting ≥48 hours, left atrial appendage thrombus must be excluded first. Patients who develop atrial fibrillation perioperatively have an increased long-term risk of thromboembolism and stroke［68］; therefore, anticoagulation should be initiated based on thrombosis and bleeding risk assessments. If started postoperatively, the anticoagulation course should be re-evaluated after 3 months according to atrial fibrillation status.
The flowchart for perioperative management of cardiovascular diseases during NCS is shown in Figure 4.
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To accurately assess the risk of cardiovascular events perioperatively in NCS, comprehensive history taking, physical examination, and evaluation of daily activity tolerance should be performed before elective NCS. Low-risk patients often do not require extensive cardiovascular tests, while those at higher risk, especially with limited functional capacity, need comprehensive evaluation. Patients with concomitant acute coronary syndrome (ACS), acute heart failure, other cardiovascular emergencies, severe valvular heart disease, treatable arrhythmias, or uncontrolled hypertension require multidisciplinary consultation to decide perioperative strategies. Patients on long-term oral antiplatelet or anticoagulant therapy, especially those recently undergoing coronary intervention, require perioperative management and medication adjustment based on NCS type. Recommendations for special populations and clinical conditions lack support from large-scale, multicenter randomized trials; thus, decision-making in these cases should emphasize multidisciplinary discussion and individualized risk assessment and management. Future high-quality clinical research reflecting domestic clinical realities is needed to improve perioperative cardiovascular risk assessment, cardiovascular disease prevention, and reduce the societal burden of cardiovascular diseases in China.
Contributing Experts (in alphabetical order by surname): Jun Bu (Renji Hospital, Shanghai Jiao Tong University School of Medicine), Ning Guo (First Affiliated Hospital of Xi’an Jiaotong University), Xiaogang Guo (First Affiliated Hospital, Zhejiang University School of Medicine), Yingcong Liang (Guangdong Provincial People’s Hospital), Yongbai Luo (First Affiliated Hospital of Xi’an Jiaotong University), Bei Shi (Affiliated Hospital of Zunyi Medical University)
Expert Group Members (in alphabetical order by surname): Jiyan Chen (Guangdong Provincial People’s Hospital), Peng Dong (Hangzhou Normal University Affiliated Hospital), Guosheng Fu (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine), Yaling Han (Shenyang Military General Hospital), Pengcheng He (Guangdong Provincial People’s Hospital), Yihe Hu (First Affiliated Hospital, Zhejiang University School of Medicine), Xinqun Hu (Second Xiangya Hospital, Central South University), Zhiqian Hu (Tongji Hospital, Tongji University), Xiaofei Jiang (Zhuhai People’s Hospital), Xinjun Lei (First Affiliated Hospital of Xi’an Jiaotong University), Lei Li (First Affiliated Hospital of Xi’an Jiaotong University), Xuebo Liu (Tongji Hospital, Tongji University), Chengliang Mao (Guangdong Provincial People’s Hospital), Peng Qu (Second Affiliated Hospital, Dalian Medical University), Xinyu Ren (Aviation General Hospital of China Medical University), Guifu Wu (Eighth Affiliated Hospital, Sun Yat-sen University), Yongjian Wu (Fuwai Hospital Chinese Academy of Medical Sciences), Dingli Xu (Nanfang Hospital, Southern Medical University), Ling Xue (Guangdong Provincial People’s Hospital), Zuyi Yuan (First Affiliated Hospital of Xi’an Jiaotong University), Qingshi Zeng (Guangdong Provincial People’s Hospital), Ruiyan Zhang (Ruijin Hospital, Shanghai Jiao Tong University School of Medicine), Zheng Zhang (First Hospital of Lanzhou University)
Conflict of Interest All authors declare no conflicts of interest