Preoperative cardiac assessment — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 68-year-old man had PCI for chronic coronary syndrome 4 years ago and has type 2 diabetes managed with metformin and empagliflozin. He also takes bisoprolol, atorvastatin and ramipril, and has no history or signs of heart failure. He is scheduled for elective adrenal resection for a benign adenoma, which ESC 2022 Table 5 places in the high surgical risk band.^[1]

1. What 30 day risk does the ESC 2022 high surgical risk band denote, and what does the surgical risk estimate leave out? (2)^[1]
2. Which pre-operative ECG and biomarker tests does ESC 2022 recommend or advise for him, with class and level? (3)^[1]
3. Give the ESC 2022 Recommendation Table 12 row, with class and level, for each of bisoprolol, atorvastatin, ramipril and empagliflozin. (4)^[1]
4. Give one advantage of hs-cTn T/I over BNP/NT-proBNP that ESC 2022 lists. (1)^[1]

Model answers — SAQ 1

1. High surgical risk is an estimated 30 day risk of CV death, MI and stroke above 5% (1 mark).^[1] The estimate is a broad approximation that takes into account only the specific surgical intervention, without considering the patient’s comorbidities (1 mark).^[1]
2. A pre-operative 12-lead ECG is recommended in patients with known CVD or CV risk factors (including age ≥65 years), or symptoms or signs suggestive of CVD, before intermediate- and high-risk NCS (ESC 2022, Class I, Level C) (1 mark).^[1] In the same group (known CVD, CV risk factors including age ≥65 years, or symptoms suggestive of CVD), hs-cTn T or hs-cTn I is recommended before intermediate- and high-risk NCS and at 24 h and 48 h afterwards (ESC 2022, Class I, Level B) (1 mark).^[1] In the same group, measuring BNP or NT-proBNP before intermediate- and high-risk NCS should be considered (ESC 2022, Class IIa, Level B) (1 mark).^[1]
3. Bisoprolol: peri-operative continuation of beta-blockers is recommended in patients currently receiving them (Class I, Level B) (1 mark).^[1] Atorvastatin: in patients already on statins, continuing statins during the peri-operative period is recommended (Class I, Level B) (1 mark).^[1] Ramipril: in patients without HF, withholding RAAS inhibitors on the day of NCS should be considered to prevent peri-operative hypotension (Class IIa, Level B) (1 mark).^[1] Empagliflozin: it should be considered to interrupt SGLT-2 inhibitor therapy for at least 3 days before intermediate- and high-risk NCS (Class IIa, Level C) (1 mark).^[1]
4. Any one: hs-cTn is more widely available; it is less expensive; if normal, it enables acute MI to be ruled out in the preceding days; or a pre-operative value enables accurate diagnosis of PMI on day 1 after surgery (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 77-year-old woman with known coronary artery disease has an elective total hip replacement. Her pre-operative hs-cTn T was 9 ng/L. On day 1 after surgery it is 41 ng/L; the assay ULN is 14 ng/L.^[1] She has no chest pain.^[1]

1. How does ESC 2022 define PMI using troponin, and does she meet it? (2)^[1]
2. If no pre-operative value had been taken, what other troponin patterns does ESC 2022 accept for a reliable diagnosis? (2)^[1]
3. In about what proportion of patients is PMI largely asymptomatic, and what is the overall 30 day mortality in patients developing PMI, according to ESC 2022? (2)^[1]
4. What should detection of PMI trigger, and what ESC 2022 row governs the next step? (2)^[1]
5. How does the Fifth Universal Definition of MI (2026) report that MINS has been defined? (2)^[6]

Model answers — SAQ 2

1. ESC 2022: an absolute increase in hs-cTn of more than the ULN on day 1 or 2 after surgery, compared with the pre-operative level, is defined as PMI (1 mark).^[1] Her rise is 32 ng/L against a ULN of 14 ng/L, so she meets the definition (1 mark).^[1]
2. A very high hs-cTn T/I on day 1, for example more than five times the ULN (1 mark).^[1] Or a relevant change from day 1 to day 2, an absolute increase or decrease of more than the ULN compared with day 1 (1 mark).^[1]
3. PMI is largely asymptomatic in about 90% of patients and is therefore missed in routine practice without surveillance (1 mark).^[1] Overall 30 day mortality in patients developing PMI is about 10% (1 mark).^[1]
4. Detection of PMI should trigger ECG recording and detailed clinical evaluation for PMI work-up and therapy (1 mark).^[1] Systematic PMI work-up is recommended to identify the underlying pathophysiology and define therapy (ESC 2022, Class I, Level B) (1 mark).^[1]
5. The Fifth UDMI (2026) reports that MINS has been defined as a subset of PMI in patients in whom myocardial injury was deemed most likely due to myocardial ischaemia (1 mark).^[6] That is in the absence of unexpected physiological stress from surgery or evidence of a cardiac non-coronary aetiology (1 mark).^[6]