Guidelines

South African cardiovascular risk stratification guideline for non-cardiac surgery

C S Alphonsus, N Naidoo, P Motshabi Chakane, I Cassimjee, L Firfiray, H Louwrens, J van der Westhuizen, A Malan, S Spijkerman, H Kluyts, N J Cloete, T Kisten, N B Nejthardt, B M Biccard

Abstract


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


Authors' affiliations

C S Alphonsus, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa; Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa

N Naidoo, Department of Vascular Surgery, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

P Motshabi Chakane, Department of Anaesthesia, University of the Witwatersrand, Johannesburg, South Africa

I Cassimjee, Department of Vascular Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa

L Firfiray, Department of Anaesthesiology and Critical Care, Tygerberg Hospital, Cape Town, South Africa

H Louwrens, Department of Vascular Surgery, Tygerberg Hospital, Cape Town, South Africa

J van der Westhuizen, Department of Anaesthesia, University of the Free State, Bloemfontein, South Africa

A Malan, Department of Vascular Surgery, University of the Free State, Bloemfontein, South Africa

S Spijkerman, Department of Anaesthesia, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa

H Kluyts, Department of Anaesthesia, Sefako Makgatho Health Sciences University and Dr George Mukhari Academic Hospital, Johannesburg, South Africa

N J Cloete, Department of Surgery, Vascular Unit, Sefako Makgatho Health Sciences University and Dr George Mukhari Academic Hospital, Johannesburg, South Africa

T Kisten, Discipline of Anaesthetics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa

N B Nejthardt, Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa

B M Biccard, Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa

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Cite this article

South African Medical Journal 2021;111(10b):.

Article History

Date submitted: 2021-10-29
Date published: 2021-10-29

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