Preoperative cardiac assessment for non-cardiac surgery

This page covers the cardiac assessment of an adult before non-cardiac surgery (NCS). It deals with surgical and patient risk, the tests to order, the common cardiac drugs, the cardiac conditions that change the plan, and the watch for peri-operative myocardial infarction/injury (PMI) afterwards. The core source is the 2022 ESC guideline on NCS.^[1] Newer rows come from the ESC/EACTS valve guideline (2025) and the ESC atrial fibrillation (2024) and cardiomyopathy (2023) guidelines, alongside ESC 2024 hypertension guideline text and the Fifth Universal Definition of MI (2026).^{[2][4][3][5][6]} Peri-operative antiplatelet and anticoagulant management after stenting is covered in DAPT complications: bleeding, switching and surgery. Anticoagulation and bridging with a mechanical valve are covered in Prosthetic heart valves: choice, anticoagulation and thrombosis.

Total risk: the operation and the patient

ESC 2022 says CV morbidity and mortality in NCS are determined by two main factors: patient-related risk and the type of surgery or procedure.^[1] That includes the circumstances in which surgery takes place (experience of the institution, elective vs. emergency procedure).^[1] It says the risk may be reduced by an adequate pre-operative evaluation and proper selection of the type and timing of the procedure.^[1] Risk should be communicated to the patient in absolute terms (for example, 1 out of 100).^[1]

Surgery-related risk

ESC 2022 says surgery-related risk is determined by the type and duration of the surgery and the urgency of the procedure.^[1] Its surgical risk estimate is a broad approximation of the 30 day risk of CV death, MI and stroke.^[1] It takes into account only the specific surgical intervention, without considering the patient’s comorbidities.^[1]

ESC 2022 Table 5: surgical risk estimate according to type of surgery or intervention (all listed procedures)

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ESC 2022 explains why: any surgical procedure may raise cortisol and catecholamines as stress responses.^[1] Changes in core temperature, blood loss and fluid shifts may raise vascular resistance or cause hypotension, leading to imbalance between myocardial oxygen demand and delivery.^[1] Bleeding, transfusion, tissue injury and the inflammatory response may affect the coagulation system and induce a prothrombotic state.^[1]

Urgency matters: ESC 2022 says acute procedures in general carry a higher risk of complications than elective ones, and it uses four timing definitions.^[1]

ESC 2022 timing definitions for surgery (text; no class or level given)

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ESC 2022 Recommendation Table 1: endovascular or video-assisted procedures should be considered for patients with high CV risk undergoing vascular or pulmonary surgery (Class IIa, Level B).^[1]

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Patient-related risk

ESC 2022 says patient-related risk is determined by age, CV risk factors, established CV disease and comorbidities.^[1] Its examples of risk factors are smoking, hypertension, diabetes, dyslipidaemia and family disposition.^[1] As an initial assessment, it recommends that all patients scheduled for NCS have an accurate history and physical examination.^[1] The emphasis is on CV risk factors, established CV disease and comorbidities.^[1] It also recommends standard laboratory tests (for example haemoglobin and renal function) in all patients undergoing intermediate- to high-risk surgery.^[1] An ECG, an assessment of functional capacity and/or biomarkers (cardiac troponins and/or NT-proBNP/BNP) are then recommended depending on the patient-related and surgery-related risk (Figure 2 of the guideline).^[1]

ESC 2022 Recommendation Table 2: recommendations for all patients scheduled for non-cardiac surgery (all rows)

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The ESC 2022 Figure 2 legend lists the CV risk factors it means: hypertension, smoking, dyslipidaemia, diabetes and family history of CVD.^[1] It defines functional capacity by the Duke Activity Status Index (DASI) or the ability to climb two flights of stairs.^[1] Its biomarker footnote reads hs-cTn T/I (Class I) and/or BNP/NT-proBNP (Class IIa), and if pathological, consult a cardiologist.^[1]

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Family history needs its own step.^[1] ESC 2022 recommends an ECG and TTE before NCS in patients with a family history of genetic cardiomyopathy, regardless of age and symptoms.^[1] That is Recommendation Table 3, Class I, Level C.^[1] The newer ESC 2023 cardiomyopathy guideline words its row differently.^[3] In patients aged <65 years with a first-degree relative with a cardiomyopathy, an ECG and TTE are recommended before NCS, regardless of symptoms (ESC 2023 Recommendation Table 33, Class I, Level C).^[3]

New murmur, chest pain, breathlessness or oedema

ESC 2022 notes that murmurs, chest pain, dyspnoea and oedema may suggest severe CVD but may also be caused by non-cardiac disease.^[1] In a patient with a murmur but no symptoms of CVD, it says the value of an echocardiogram is not well established and consensus is missing.^[1] For dyspnoea, if NT-proBNP/BNP is elevated an echocardiogram should be performed; if it is not, other reasons for dyspnoea should be explored.^[1]

ESC 2022 Recommendation Table 4: pre-operative assessment in patients with previously unknown murmur, angina, dyspnoea, or peripheral oedema (all rows)

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In an elective setting, if the symptoms are suggestive of CAD, ESC 2022 says the guidelines for CAD patients in the non-surgical setting should be followed.^[1] If immediate, urgent or time-sensitive NCS is needed, time and access to diagnostic tools may be limited.^[1] ECG and troponins can still be used to detect or exclude ACS.^[1]

When the heart argues against operating

ESC 2022 says that, in general, the risk for the patient if not operated on must be considerably higher than the risk of the treatment.^[1] It gives no definite list of cardiac contraindications.^[1] It says high-risk NCS should probably be avoided in patients with severe HF (NYHA class IV), cardiogenic shock, severe pulmonary hypertension or severe frailty.^[1] The decision should be made after discussions between the surgeon, anaesthesiologist, cardiologist, and a geriatrician for elderly patients, along with the patient and relatives.^[1] ESC 2022 also recommends individualized instructions for pre-operative and post-operative changes in medication.^[1] They should be given in verbal and written formats with clear and concise directions (Recommendation Table 5, Class I, Level C).^[1]

Risk scores, frailty and functional capacity

ESC 2022 says most risk calculators integrate patient-related and surgery-related factors, but none include biomarkers among their variables.^[1] Its Task Force decided against recommending one specific risk score, and decided that selection for further pre-operative testing should rest on clinical criteria rather than a specific score.^[1] It says there is significant variability in predicted risk between tools and none can be disqualified with current evidence.^[1]

The Revised Cardiac Risk Index (RCRI) estimates the risk of 30 day mortality, MI or cardiac arrest and is based on six variables.^[1] ESC 2022 Table 6 (risk score calculators) lists them.^[1] They are ischaemic heart disease, cerebrovascular disease, history of congestive heart failure, insulin therapy for diabetes, serum creatinine ≥2 mg/dL and high-risk surgery, each assigned 1 point.^[1] The ESC 2022 text says a score of 0 indicates a 4% risk of 30 day mortality, MI or cardiac arrest; 1, 6%; 2, 10%; and ≥3, 15%.^[1] The RCRI can be used without a web connection, whereas the ACS NSQIP calculator is procedure-specific and only available on the web.^[1] The AUB-HAS2 index is the most recently developed index for 30 day death, MI or stroke.^[1] It stratifies patients into low (score 0–1), intermediate (2–3) and high risk (>3), and scores >3 denote a post-operative event rate of >10%.^[1]

ESC 2022 defines frailty as an age-related, multidimensional state of decreased physiological reserve with diminished resiliency, loss of adaptive capacity and increased vulnerability to stressors.^[1] It says the evaluation of elderly patients (>70 years) who need elective intermediate- or high-risk NCS should include frailty screening.^[1] Frailty screening is an excellent predictor of unfavourable outcomes in older surgical patients.^[1] The Frailty Index and the Frail Phenotype are the most commonly recommended tools, and the Clinical Frailty Scale is a simpler approach that relies on history taking.^[1]

On functional capacity, ESC 2022 says METs <4 have long been considered to indicate poor functional capacity.^[1] Studies using METs, however, were based on subjective interviews and have not shown proven value.^[1] ESC 2022 cites a large prospective cohort of high-risk patients undergoing NCS.^[1] There, self-reported inability to climb two flights of stairs added incremental value to the RCRI for the 30 day cardiac event rate.^[1] That cohort’s own abstract (2021) describes a predefined secondary analysis of a prospective diagnostic cohort study: 4560 consecutive patients at elevated CV risk having in-patient NCS.^[1][17] In it, functional capacity of less than two flights of stairs was associated with the 30-day composite of cardiac death and cardiac events (adjusted HR 1.63, 95% CI 1.23–2.15), and adding it to the RCRI improved risk classification.^[17]

ESC 2022 separately reports the METS study, in which the DASI estimated cardiac risk more precisely than subjectively assessed functional capacity and improved risk estimation with the RCRI.^[1] The METS abstract (2018) describes a multicentre, international, prospective cohort study at 25 hospitals in Canada, the UK, Australia and New Zealand, comparing subjective assessment with CPET, DASI and NT-proBNP.^[18] Between March 2013 and March 2016 it included 1401 adults aged at least 40 years scheduled for major NCS who were deemed to have one or more risk factors for cardiac complications (for example a history of HF, stroke or diabetes) or coronary artery disease.^[18] Its primary outcome, death or MI within 30 days after surgery, was assessed in participants who underwent both CPET and surgery.^[18] It occurred in 28 of 1401 patients (2%), and only DASI scores were associated with predicting it (adjusted OR 0.96, 95% CI 0.83–0.99).^[18] ESC 2022 adds, citing METS and the stairs cohort above, that cardiopulmonary exercise testing (CPET) did not predict 30 day mortality, post-operative MI or cardiac arrest, noting that a relatively low number of primary outcome events limited the statistical power.^[1]

For a DASI threshold, ESC 2022 cites a separate report: a DASI score <34 was associated with increased odds of 30 day death or MI.^[1] That report (2020) is a nested cohort analysis of METS in 1546 participants aged 40 years or older at elevated cardiac risk who had inpatient NCS.^[1][30] Its abstract says functional capacity worse than a DASI score of 34 was associated with increased odds of 30-day death or MI (OR 1.05 per 1-point decrease below 34; 95% CI 1.00–1.09).^[30]

ESC 2022 Recommendation Table 6: pre-operative assessment of frailty and functional capacity (all rows)

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Biomarkers: troponin and natriuretic peptides

ESC 2022 says high-sensitivity cardiac troponin T/I (hs-cTn T/I) quantifies myocardial injury, while BNP and NT-proBNP quantify haemodynamic cardiac wall stress.^[1] Both complement clinical assessment and the ECG in risk prediction.^[1] Several large prospective studies have shown that both hs-cTn T/I and BNP/NT-proBNP have high and incremental prognostic value for peri-operative cardiac complications, including CV death, cardiac arrest, acute HF and tachyarrhythmias.^[1]

ESC 2022 reports a cohort of nearly 1000 patients undergoing major elective NCS.^[1] Pre-operative hs-cTn T >14 ng/L carried an in-hospital mortality of 6.9% vs. 1.2% with hs-cTn T ≤14 ng/L (P < 0.001; AUC 0.81).^[1] That study’s abstract (2013) describes a prospective, international multicentre observational study of 979 patients before NCS, with in-hospital mortality among its endpoints.^[1][19] It gives the same 6.9% vs. 1.2% mortality split at an hs-cTn T cut-off of 14 ng/L, and an AUC of 0.809 for hs-cTn T as a predictor of mortality.^[19] ESC 2022 also reports a prospective cohort of 10 402 patients from 16 centres in which NT-proBNP improved risk prediction beyond the RCRI.^[1] That cohort’s abstract (2020) describes 10 402 patients aged 45 years or older having inpatient NCS at 16 hospitals in 9 countries.^[1][20] Its outcome was the composite of vascular death and MINS within 30 days, and adding NT-proBNP thresholds to the RCRI gave a net absolute reclassification improvement of 258 per 1000 patients.^[20] Overall, ESC 2022 says hs-cTn T/I and BNP/NT-proBNP seem to have comparable accuracy in predicting cardiac complications.^[1]

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ESC 2022 Recommendation Table 7: pre-operative risk assessment, electrocardiography and biomarkers (all rows)

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The table footnotes define the abnormal results.^[1] An abnormal ECG is a pathological Q wave, ST-T wave changes, non-sinus rhythm or left bundle branch block.^[1] An abnormal pre-operative hs-cTn T/I is more than the ULN.^[1] Age, sex and known cardiac disease should also be considered when interpreting the pre-operative troponin.^[1] An abnormal BNP is ≥35 pg/mL and an abnormal NT-proBNP ≥125 pg/mL.^[1] Both are to be read as quantitative markers of heart failure that also take into account age, sex, obesity and known cardiac disease.^[1] ESC 2022 notes that age, renal dysfunction and obesity are important confounders in the age group in which BNP/NT-proBNP is recommended, while sex has less impact.^[1]

Pre-operative testing: ECG, echo, stress imaging and angiography

Electrocardiography

ESC 2022 describes the 12-lead ECG as a widely available, simple and inexpensive tool.^[1] It can semi-quantitatively assess cardiac risk (for example Q waves of previous MI) and detect unknown conditions that need therapy, such as atrial fibrillation or AV block.^[1] The ECG row is the first row of Recommendation Table 7 above (Class I, Level C).^[1] The guideline text adds that a routine pre-operative ECG is not recommended in low-risk patients undergoing low-risk NCS.^[1]

Transthoracic echocardiography

ESC 2022 says that in large retrospective cohorts, routine pre-operative TTE before high-risk NCS did not reduce post-operative MACE or add information over clinical risk models.^[1] It lists appropriate indications for TTE: poor exercise tolerance, an abnormal ECG, or unexplained dyspnoea.^[1] Suspected new or significant CVD without follow-up within the last 90 days, or coexisting clinical risk factors, are also on the list.^[1] TTE informs on three main risk markers for post-operative cardiac events: LV dysfunction, valve disease and cardiomyopathies.^[1] A FOCUS examination lacks spectral Doppler, so it is only accurate for main structural and functional abnormalities.^[1]

ESC 2022 Recommendation Table 8: transthoracic echocardiography (all rows; footnotes: functional capacity as in Section 4.2; high NT-proBNP/BNP ≥125 pg/mL/35 pg/mL)

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Stress testing

ESC 2022 says an exercise stress test alone should only be considered a valuable alternative for diagnosing obstructive CAD if non-invasive imaging tests are unavailable.^[1] The other use is assessing functional capacity when the clinical history is ambiguous.^[1] Stress imaging is appropriate for risk assessment in patients with clinical risk factors and poor functional capacity.^[1] It is not recommended in patients undergoing urgent surgery or with an unstable clinical condition.^[1] Normal stress imaging without resting abnormalities has a high negative predictive value.^[1] The positive predictive value for peri-operative events is relatively low and requires confirmation by other tests.^[1]

ESC 2022 Recommendation Table 9: stress imaging (all rows)

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The footnotes to the first row define its terms: poor functional capacity is based on the DASI or inability to climb two flights of stairs.^[1] High likelihood of CAD is a pre-test probability >15% based on age, sex and nature of symptoms.^[1] Two or more CVD risk factors (dyslipidaemia, diabetes, hypertension, smoking, family history of CVD) also count.^[1] So do resting ECG changes (Q wave or ST-segment/T wave changes) or LV dysfunction suggestive of CAD.^[1] High clinical risk is one or more RCRI clinical risk factors.^[1] These are ischaemic heart disease, cerebrovascular disease, history of congestive heart failure, serum creatinine >2 mg/dL, or diabetes requiring insulin therapy.^[1]

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Coronary angiography

ESC 2022 says CAD may be present in a significant number of patients needing NCS.^[1] Even so, the indications for pre-operative coronary angiography and revascularization are similar to those in the non-surgical setting.^[1] It warns that invasive angiography may cause an unnecessary and unpredictable delay to planned surgery and adds an independent procedural risk.^[1]

ESC 2022 Recommendation Table 10: coronary angiography (all rows)

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Peri-operative medication

Two ESC 2022 lifestyle rows open the list (Recommendation Table 11).^[1] Smoking cessation more than 4 weeks before NCS is recommended to reduce post-operative complications and mortality (ESC 2022, Class I, Level B).^[1] Control of CV risk factors, including blood pressure, dyslipidaemia and diabetes, is recommended before NCS (ESC 2022, Class I, Level B).^[1]

ESC 2022 Recommendation Table 12: pharmacological treatment (all rows)

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Beta-blockers

ESC 2022 reports POISE-1, the largest trial on pre-surgery initiation.^[1] It describes 8351 patients with or at risk of atherosclerotic disease, not on beta-blockers before NCS, randomized to extended-release metoprolol succinate 200 mg daily or placebo, started 2–4 h before surgery and maintained for 30 days.^[1] The POISE-1 abstract (2008) describes a randomised controlled trial in 190 hospitals in 23 countries in 8351 patients with, or at risk of, atherosclerotic disease undergoing NCS, with treatment started 2–4 h before surgery and continued for 30 days.^[21] Fewer patients reached the primary endpoint of CV death, non-fatal MI and non-fatal cardiac arrest: 5.8% with metoprolol vs. 6.9% with placebo (HR 0.84, 95% CI 0.70–0.99; p=0.0399).^[21] More patients died (3.1% vs. 2.3%) and more had a stroke (1.0% vs. 0.5%) with metoprolol than with placebo.^[21] ESC 2022 adds that clinically significant hypotension or bradycardia was also significantly higher in the metoprolol arm.^[1] It says the high dose of extended-release metoprolol might have played a role in the adverse events.^[1]

ESC 2022 says initiation of beta-blockers before NCS was not associated with a net clinical benefit in most analyses.^[1] It adds that they might be beneficial in patients with high CV risk profiles or undergoing high-risk surgery, including vascular interventions.^[1] When oral beta-blockade is started in CAD patients, atenolol or bisoprolol as a first choice may be considered.^[1] The footnotes to the initiation rows add detail, row by row.^[1] For the row on two or more clinical risk factors before high-risk NCS, initiation is ideally at least 1 week before surgery, starting with a low dose titrated to a resting heart rate of 60–70 b.p.m. with systolic blood pressure >100 mmHg.^[1] Its clinical risk factors are ischaemic heart disease, cerebrovascular disease, renal insufficiency or diabetes mellitus according to the RCRI score.^[1] For the row on known CAD or myocardial ischaemia, treatment should ideally be started between 30 and (at least) 2 days before surgery at a low dose, and should be continued post-operatively.^[1]

For chronic users, ESC 2022 says beta-blockers should be maintained.^[1] Increased mortality after pre-operative withdrawal has been reported in five observational studies, and interrupting therapy for >2 days post-operatively may double the risk of AF.^[1] Post-operative tachycardia should first lead to treatment of the underlying cause, such as hypovolaemia, pain, blood loss or infection, rather than simply increasing the beta-blocker dose.^[1] The newer ESC 2024 hypertension guideline text agrees that routine peri-operative initiation of a beta-blocker is not necessary.^[5]

Statins

ESC 2022 reports the LOAD trial in 648 statin-naïve patients (24% with a history of CVD, 49% with diabetes).^[1] The LOAD abstract (2017) describes a randomized trial in 648 statin-naïve patients scheduled for NCS and at risk for a major vascular complication.^[22] They received atorvastatin or placebo: 80 mg any time within 18 hours before surgery, a 40 mg maintenance dose started at least 12 hours after surgery, then 40 mg/day for 7 days.^[22] The primary composite of all-cause mortality, non-fatal MINS and stroke at 30 days occurred in 16.6% with atorvastatin vs. 18.7% with placebo (HR 0.87, 95% CI 0.60–1.26; P=.46).^[22] ESC 2022 judges the trial underpowered to draw definite conclusions.^[1] ESC 2022 therefore says routine peri-operative initiation of statins is not recommended.^[1] In patients in whom statin use is already indicated, treatment should be considered peri-operatively, particularly before high-risk surgery such as vascular surgery.^[1]

ACE inhibitors and ARBs

ESC 2022 calls the data on peri-operative RAAS inhibitors inconclusive.^[1] Most studies suggest that continued use is associated with a higher risk of peri-operative hypotension and, as a consequence, higher use of vasopressors and inotropes.^[1] If an ACEI/ARB is withheld before NCS, it should be restarted as soon as possible to prevent unintended long-term omission.^[1] There are no data on peri-operative effects of ARNI, but hypotension is more common than with ACEI.^[1] In 2022 the guideline listed STOP-or-NOT and POISE-3 as ongoing trials; both have since reported, along with SPACE and PAAB.^{[1][8][10][7][9]}

Newer randomized evidence on RAS inhibitors and peri-operative blood pressure strategy (dated trial abstracts)

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The SPACE authors concluded that stopping RAS inhibitors did not reduce myocardial injury and could increase clinically significant acute hypertension.^[7] They said their findings need confirmation.^[7] The PAAB authors concluded that, in patients with low cardiac risk, withholding for 24 h did not reduce MACE, intra-operative hypotension or AKI.^[9] The ESC 2022 rows predate these reports; the newer ESC 2024 hypertension guideline adds that withholding ACE inhibitors has also been shown to increase post-operative hypertension.^[1][5]

Other cardiac drugs

Calcium channel blockers: ESC 2022 says patients already on CCBs, particularly with vasospastic angina, should continue them peri-operatively.^[1] The dose on the day of surgery is withheld to avoid post-operative hypotension.^[1] ESC 2024 hypertension says CCBs are generally considered safe pre-operatively.^[5] Diuretics: in HF the dose should be adjusted well in advance for optimal fluid balance.^[1] Any electrolyte disturbance, especially hypokalaemia and hypomagnesaemia, should be corrected in due time before surgery.^[1] Alpha-2 agonists: ESC 2022 reports POISE-2, in which 10 010 patients undergoing NCS were randomized to clonidine or placebo.^[1] The POISE-2 abstract (2014) describes a blinded, 2-by-2 factorial randomized trial at 135 centres in 23 countries in patients with, or at risk for, atherosclerotic disease undergoing NCS.^[23] Clonidine 0.2 mg per day or placebo was given just before surgery and continued until 72 hours after surgery.^[23] Clonidine did not reduce the 30 day composite of death or non-fatal MI (HR 1.08, 95% CI 0.93–1.26), but more patients had clinically important hypotension (47.6% vs. 37.1%) and non-fatal cardiac arrest (0.3% vs. 0.1%).^[23]

Ivabradine: ESC 2022 called it a negative chronotropic agent without a hypotensive effect and a possible alternative to beta-blockers, with few studies in high-risk NCS.^[1] A later multicentre, double-blind, placebo-controlled trial (2025) randomized 2101 patients aged ≥45 years with, or at risk of, atherosclerotic disease who were undergoing NCS.^[11] They received ivabradine 5 mg twice daily for up to 7 days, starting 1 hour before surgery, or placebo.^[11] MINS within 30 days occurred in 17.0% vs. 15.1% (RR 1.12, 95% CI 0.92–1.37), and enrolment was halted for futility at the interim analysis.^[11]

SGLT-2 inhibitors

ESC 2022 calls euglycaemic diabetic ketoacidosis (EDKA) a rare but serious complication that may occasionally occur after surgery in patients on SGLT-2 inhibitors.^[1] It reports that the US FDA recommends interrupting SGLT-2 inhibitors for at least 3–4 days before scheduled surgery and being vigilant for EDKA symptoms, prompting ketone measurement.^[1] Its own row, as above, is that interrupting therapy for at least 3 days before intermediate- and high-risk NCS should be considered (Class IIa, Level C).^[1]

Newer, non-randomized evidence questions this.^[12] A 2026 secondary analysis drew on two prospective cohorts in major NCS (Basel-PMI and PMI-Vital).^[12] It included 451 patients on chronic SGLT2 inhibitors; 89.6% had diabetes and 36.9% chronic HF.^[12] Each day of pre-operative discontinuation was associated with more acute HF hospitalisation or CV death within 90 days (adjusted OR 1.58 per day, 95% CI 1.08–2.30).^[12] Its authors say this suggests potential harm in current guideline recommendations and that randomised trials are needed.^[12] A 2026 SPAQI multidisciplinary consensus statement used a modified Delphi process with a systematic review.^[13] It proposes a tailored approach based on diabetes, other comorbidities, surgical and periprocedural dietary considerations, and monitoring and prevention strategies for EDKA.^[13] It is a consensus statement, not a guideline, so no class is given here.^[13]

Antithrombotic drugs

ESC 2022 says efficient peri-operative management of antithrombotic therapy aims to offer the potential benefit of preventing thrombotic events without excessive bleeding complications.^[1] Three of its antiplatelet rows cover timing and planning after PCI or ACS (ESC 2022 Recommendation Table 13, selected rows).^[1] Elective NCS should be delayed until 6 months after elective PCI and 12 months after an ACS (ESC 2022, Class I, Level A).^[1] After elective PCI, time-sensitive NCS should be delayed until at least 1 month of DAPT has been given (ESC 2022, Class I, Level B).^[1] With a recent PCI, antiplatelet management should be discussed between surgeon, anaesthesiologist and cardiologist (ESC 2022, Class I, Level C).^[1] The full antiplatelet and anticoagulant rows, including interruption intervals and bridging, are covered in DAPT complications: bleeding, switching and surgery.

Specific conditions

Coronary artery disease

ESC 2022 says the peri-operative risk in established CAD depends on baseline CV risk, the type of surgery and the urgency of NCS.^[1] Older patients have a higher risk than younger ones, and patients with a recent ACS have a higher risk than those with CCS.^[1] In known CAD it recommends collecting information on previous invasive and non-invasive tests and coronary interventions in good time, ideally when NCS is first proposed.^[1] A patient scheduled for elective NCS who presents with an ACS should be managed as for ACS in the non-surgical setting.^[1] Treating the culprit lesion only before NCS would be reasonable to consider.^[1]

ESC 2022 reports CARP, in which 510 patients with CCS were randomized to optimal medical therapy or coronary revascularization before major vascular surgery.^[1] The CARP abstract (2004) describes a randomized trial in patients at increased risk of peri-operative cardiac complications with clinically significant CAD.^[24] Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centres, 510 were randomly assigned to coronary revascularization or none before elective major vascular surgery.^[24] Its primary end point was long-term mortality, which at 2.7 years was 22% with revascularization vs. 23% without (RR 0.98, 95% CI 0.70–1.37).^[24] Post-operative MI within 30 days of the vascular operation, defined by elevated troponin levels, occurred in 12% with revascularization vs. 14% without (P=0.37).^[24] ESC 2022 gives acute MI after 30 days as 8.4% vs. 8.4%, which differs from the troponin-defined rates in the trial abstract.^[1][24] ESC 2022 notes that the trial excluded significant left main disease and that one-third of patients had three-vessel disease.^[1] ESC 2022 also reports a later meta-analysis of 3949 patients that showed no clinical benefit from routine prophylactic revascularization before NCS.^[1] That meta-analysis (2007) pooled one randomized controlled trial and six retrospective studies, 3949 patients undergoing high-risk NCS in all.^[1][25] It found no significant difference between revascularization and medical management in post-operative mortality or MI, and no long-term outcome benefit.^[25]

ESC 2022 Recommendation Table 19: timing of non-cardiac surgery and revascularization in patients with known coronary artery disease (all rows)

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Heart failure and cardiomyopathy

ESC 2022 calls HF an established risk factor for post-operative mortality across a broad range of surgical specialties.^[1] It reports an analysis of 21 560 996 hospitalizations for NCS in which any HF diagnosis was associated with significantly higher in-hospital all-cause mortality than no HF (4.8% vs. 0.78%; adjusted OR 2.15).^[1] That analysis’s abstract (2021) identifies the hospitalizations from the Healthcare Cost and Utilization Project National Inpatient Sample: adults ≥18 years having non-cardiac surgery between 2012 and 2014, 4.9% of them with an HF diagnosis.^[1][26] It reports in-hospital mortality as more common with any HF diagnosis than without (4.8% vs. 0.78%; adjusted OR 2.15, 95% CI 2.09–2.22).^[26] ESC 2022 says elective NCS is not recommended in patients with decompensated HF.^[1] The TTE should be no older than 6 months, or repeated just before NCS if the patient worsens clinically.^[1] Optimal guideline-directed treatment of HF before scheduled NCS is recommended to reduce the risk of acute decompensation and death.^[1] In patients with CRT devices, the device should be kept on for better haemodynamic stability.^[1]

HF rows: ESC 2022 Recommendation Table 20 (all rows) and ESC 2023 cardiomyopathy Recommendation Table 33 (all rows)

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The ESC 2023 cardiomyopathy row on LV function is newer and also covers intermediate-risk NCS, but only in cardiomyopathy.^[3][1] It applies to cardiomyopathy with suspected or known HF, so the ESC 2022 row remains the one for HF in general.^[3][1] In hypertrophic cardiomyopathy with LV outflow tract obstruction, ESC 2022 says complication risk during NCS is increased.^[1] Prolonged pre-operative fasting and dehydration should be avoided to maintain stroke volume and reduce the risk of increased obstruction, and the heart rate should be kept low (60–65 b.p.m.) with AF avoided.^[1] Patients with ventricular assist devices should have NCS in centres with access to VAD teams.^[1]

Valvular heart disease

ESC 2022 says valve-related risk is particularly increased with obstructive lesions such as symptomatic AS or MS, where peri-operative volume shifts and arrhythmia may lead to rapid decompensation.^[1] Patients in whom mild-to-moderate valve disease was diagnosed more than 1 year earlier should have clinical and echocardiographic re-assessment.^[1] Severe symptomatic AS is a significant risk factor for post-operative MI and HF.^[1] Asymptomatic severe AS with normal LVEF can safely undergo low- to intermediate-risk NCS, unless the surgery involves large volume shifts.^[1] In mild-to-moderate AR, NCS can be performed without additional risk, while patients with secondary MR, especially of ischaemic aetiology, are at increased CV risk during NCS.^[1] In MS, arterial vasodilators should be avoided and surveillance for peri-operative AF is of paramount importance.^[1]

ESC 2022 Recommendation Table 21: management of valvular heart disease in patients undergoing non-cardiac surgery (all rows)

^[1]

The newer ESC/EACTS 2025 valve guideline keeps the same direction in its Section 15 text, which carries no class or level.^[2] It says echocardiography should be performed in all patients with valve disease requiring NCS.^[2] In severe symptomatic AS, it says treatment depends on the urgency and risk of NCS, and urgent low- and intermediate-risk NCS can be performed relatively safely.^[2] If life-saving time-sensitive NCS is needed, it should be performed under careful haemodynamic monitoring avoiding rapid changes of volume status, with prompt treatment of arrhythmia regardless of AS severity.^[2] Before urgent high-risk NCS, TAVI or balloon aortic valvuloplasty should be considered in critical AS, bearing in mind the risk of severe acute AR after valvuloplasty.^[2] In severe symptomatic AS, when NCS can be deferred, a pre-operative Heart Team should decide whether SAVR or TAVI is preferable.^[2] TAVI may be preferred if faster recovery matters, particularly in elderly patients facing complex or high-risk NCS.^[2] Treatment of asymptomatic severe AS should be individualized.^[2] Its key message on symptomatic severe AS adds that in patients planned for elective NCS, AV intervention is recommended prior to NCS (no class or level given).^[2] Among the rows of its Recommendation Table 4 (intervention in symptomatic and asymptomatic severe AS), the one that names NCS is a balloon valvotomy row.^[2] Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients and, if feasible, in those with severe AS who require urgent high-risk NCS (ESC/EACTS 2025, Class IIb, Level C).^[2]

For MS, ESC/EACTS 2025 says heart rate and fluid balance should be controlled to prevent pulmonary oedema during NCS, and arterial vasodilators should be avoided.^[2] It says NCS is safe with an MVA >1.5 cm², and in asymptomatic patients with MVA ≤1.5 cm² and SPAP <50 mmHg.^[2] Symptomatic patients or those with SPAP >50 mmHg should undergo PMC or other appropriate valve intervention before high-risk NCS, if possible.^[2] It adds that asymptomatic patients with MVA ≤1.5 cm² can undergo low-to-moderate-risk NCS under careful monitoring, especially if PMC is unsuitable, and that multidisciplinary management is advised for significant MS ineligible for valve intervention.^[2] Among the MS rows of its Recommendation Table 8 (PMC, MV surgery and transcatheter intervention in clinically severe rheumatic and degenerative MS), the one that names NCS is a PMC row.^[2] PMC should be considered in asymptomatic patients without unfavourable clinical and anatomical characteristics for PMC who also have high thromboembolic risk and/or high risk of haemodynamic decompensation (ESC/EACTS 2025, Class IIa, Level C).^[2] The row gives high thromboembolic risk as history of systemic embolism, dense spontaneous contrast in the LA, or new-onset or paroxysmal AF.^[2] It gives high risk of haemodynamic decompensation as SPAP >50 mmHg at rest, need for major NCS, pregnancy or desire for pregnancy.^[2] The ESC 2022 row in the table above stands beside these: in moderate-to-severe rheumatic MS with symptoms or SPAP >50 mmHg, valve intervention (PMC or surgery) is recommended before elective intermediate- or high-risk NCS (ESC 2022 Recommendation Table 21, Class I, Level C).^[1]

For regurgitation, ESC/EACTS 2025 says NCS can usually be performed safely in asymptomatic severe MR or AR with preserved LV function.^[2] If NCS is urgent, patients should undergo surgery under strict haemodynamic monitoring, regardless of symptom status.^[2] AR meeting the criteria for valve intervention should be treated before any elective intermediate- or high-risk NCS.^[2] In severe ventricular secondary MR before elective (non-urgent) NCS, medical therapy should be optimized; if symptoms persist and NCS is intermediate or high risk, TEER should be considered after Heart Team discussion based on clinical and anatomical selection criteria.^[2] Its primary MR intervention row defines LV dysfunction more widely than the ESC 2022 NCS row.^[2] There, LV dysfunction is LVESD ≥40 mm or LVESDi ≥20 mm/m² or LVEF ≤60% (ESC/EACTS 2025 Recommendation Table 6, Class I, Level B for MV surgery in asymptomatic severe primary MR).^[2]

With a prosthetic valve, ESC 2022 says NCS can go ahead provided there is no evidence of valve dysfunction, and the main problem is modifying anticoagulation.^[1] The newer mechanical-valve rows sit in ESC/EACTS 2025 Recommendation Table 15 (antithrombotic therapy with a mechanical heart valve undergoing elective NCS or invasive procedures) and are covered in Prosthetic heart valves: choice, anticoagulation and thrombosis.^[2]

Atrial fibrillation and other arrhythmias

ESC 2022 says SVT and VT may accompany acute surgical illness but should not defer urgent surgery unless the arrhythmia is life-threatening.^[1] Patients with a known arrhythmia undergoing elective surgery should have a pre-operative 12-lead ECG and a cardiology check-up.^[1] Patients already taking antiarrhythmic drugs should generally not stop them.^[1]

AF may be asymptomatic and first detected on admission for surgery, or first occur pre-operatively.^[1] ESC 2022 says the initial management of newly diagnosed AF includes prevention of thromboembolism and symptom control and should not wait for a cardiology consultation.^[1] It calls optimal rate control (resting heart rate <110 b.p.m.) mandatory in all patients with AF.^[1] Pre-operative rhythm control may be considered only if symptoms persist despite optimal rate control.^[1] Amiodarone can be first-line in HF, whereas digoxin is usually ineffective in high adrenergic states such as surgery.^[1] Peri-operative handling of oral anticoagulation depends on the type of surgery.^[1]

ESC 2022 Recommendation Table 22: management of known or newly diagnosed arrhythmias (all rows)

^[1]

The newer ESC 2024 AF guideline carries two general rows that apply here.^[4] Electrical cardioversion is recommended in AF patients with acute or worsening haemodynamic instability to improve immediate patient outcomes (ESC 2024 Recommendation Table 15, Class I, Level C).^[4] Lenient rate control with a resting heart rate <110 b.p.m. should be considered as the initial target (ESC 2024, Class IIa, Level B).^[4] Stricter control is reserved for continuing AF-related symptoms.^[4] Both ESC 2022 NCS (Class III, Level B) and ESC 2024 AF (Class III, Level B) say routine beta-blockers to prevent post-operative AF after NCS are not recommended.^[1][4]

Pacemakers, ICDs and other devices

ESC 2022 says that in patients undergoing elective NCS, surgery should be deferred if possible and a permanent pacemaker implanted if pacing indications are fulfilled.^[1] Prophylactic pacing for asymptomatic bifascicular block, with or without first-degree AV block, is generally not indicated.^[1] A pre-operative device check should have been done at least once within the preceding 12 months for pacemakers and within 6 months for ICDs.^[1] That applies in the absence of any malfunction, and remote monitoring can be used.^[1] The ESC 2022 text says some patients should have the device checked and reprogrammed immediately before surgery.^[1] These are pacing-dependent patients, CRT recipients and ICD recipients undergoing elective NCS with risk of electromagnetic interference (EMI), for example unipolar electrocoagulation, especially above the umbilicus.^[1] Its matching formal row says this should be considered in high-risk CIED patients undergoing NCS with a high probability of EMI (ESC 2022 Recommendation Table 23, Class IIa, Level C).^[1] Pacemaker-dependent patients should be reprogrammed to non-sensing or asynchronous pacing.^[1] A magnet is not a universal remedy, because magnet mode in modern pacemakers, except Medtronic and Sorin/Livanova/Microport, is programmable and may not be asynchronous.^[1]

For ICDs with anticipated EMI, ESC 2022 says detection or therapies should be switched off before NCS, or a magnet placed over the device.^[1] All modern ICDs respond to a magnet by inhibiting antitachycardia therapy while leaving bradycardia pacing intact.^[1] As soon as possible after NCS, the ICD should be checked and therapies switched on.^[1] Bipolar electrocautery, short bursts (<5 s) at the lowest effective energy, and a pen or stylus kept more than 15 cm from the device can minimize interference.^[1] The return pad should be placed as far from the device as possible, keeping the surgical site between the device and the return electrode.^[1]

ESC 2022 Recommendation Table 23: bradyarrhythmia and patients carrying cardiac implantable devices (all rows)

^{[1] [1]}

Hypertension

ESC 2022 says postponing surgery is usually not advised in grade 1 or 2 hypertension.^[1] With systolic BP ≥180 mmHg and/or diastolic BP ≥110 mmHg, deferring the intervention until BP is controlled is advisable, except for emergency surgery.^[1] Its rows sit in Recommendation Table 27 (all rows).^[1] In chronic hypertension undergoing elective NCS, large peri-operative fluctuations in blood pressure, particularly hypotension, should be avoided (ESC 2022, Class I, Level A).^[1] Newly diagnosed hypertensive patients scheduled for elective high-risk NCS should be screened for hypertension-mediated organ damage and CV risk factors (ESC 2022, Class I, Level C).^[1] Deferring NCS in stage 1 or 2 hypertension is not recommended (ESC 2022, Class III, Level C).^[1] The newer ESC 2024 hypertension guideline refers peri-operative detail back to the ESC NCS guideline.^[5] It says postponing necessary NCS is not usually warranted for minor or moderate BP elevations, and that planning should account for the baseline office BP.^[5]

PMI and MINS surveillance

ESC 2022 says PMI is the most common CV complication of NCS.^[1] Because of anaesthesia and analgesia, it is largely asymptomatic in about 90% of patients and is therefore missed in routine practice without surveillance.^[1] It defines PMI as acute cardiomyocyte injury (post-operative hs-cTn T/I release) with or without symptoms, and with or without ECG or imaging evidence of acute ischaemia.^[1] PMI can only be reliably and rapidly detected with hs-cTn T/I measured before and serially after surgery, for example at 24 and 48 h.^[1] ESC 2022 reports that in the BASEL-PMI study, about 15% of patients with pre-existing CAD/PAD or aged >65 years undergoing major NCS developed PMI.^[1] The report it cites for this (2021) is a prospective observational screening study of 2265 patients aged ≥65 years, or ≥45 years with a history of CVD, having NCS at a tertiary hospital.^[1][28] With serial cardiac troponin measurements, PMI occurred in 13.2% within 30 days, and any MACE in 15.2%.^[28] An earlier BASEL-PMI report (2018), a prospective diagnostic study of 2018 consecutive patients at increased CV risk with a planned post-operative stay of ≥24 hours, defined PMI as an absolute hs-cTn T rise of ≥14 ng/L from the pre-operative to the post-operative value.^[27] In that report, PMI occurred after 397 of 2546 surgeries (16%; 95% CI 14%–17%).^[27] Overall, ESC 2022 gives 30 day mortality in patients developing PMI as about 10%.^[1]

The ESC 2022 Figure 4 legend gives the working rule.^[1] An absolute increase in hs-cTn of more than the ULN on day 1 or 2 after surgery, compared with the pre-operative level, defines PMI.^[1] Without a pre-operative value, a very high day 1 concentration (for example more than five times the ULN) would also achieve a reliable diagnosis.^[1] So would a relevant change from day 1 to day 2, an absolute rise or fall of more than the ULN.^[1] Detecting PMI should trigger an ECG and detailed clinical evaluation, and the ESC 0/1/2 h algorithm has not been validated peri-operatively and cannot be used.^[1] ESC 2022 recommends the absolute-increase threshold of more than the ULN for clinical use.^[1] It is consistently associated with higher 30 day and long-term mortality, though optimal thresholds need further study.^[1]

A baseline pre-operative troponin is needed to tell an acute rise from a chronic elevation.^[1] The Fifth Universal Definition of MI (2026) explains why.^[6] Up to 40% of patients with CVD or risk factors have baseline elevated cardiac troponin, so a pre-operative value is essential if post-operative testing is planned.^[6] It says that with active troponin surveillance, PMI is found in around 1 in 8 patients undergoing high-risk NCS.^[6]

Work-up then separates causes.^[1] ESC 2022 says early differentiation of primarily non-cardiac causes (for example severe sepsis or PE) from the different cardiac causes, including type 1 MI, type 2 MI, tachyarrhythmia and acute HF, is of major importance, and TTE helps in most patients.^[1] In about half of patients with PMI the pathophysiology cannot be reliably ascertained based on the commonly available documentation, and surveillance also detects non-cardiac disorders with immediate therapeutic consequences, such as PE.^[1] ESC 2022 discussed the differential diagnosis under the fourth universal definition of MI.^[1][6] The Fifth UDMI (2026) has since proposed a new clinical classification based on pathophysiology, with its key updates from the Fourth UDMI in its Table 1.^[1][6] The Fifth UDMI (2026) says identification of PMI or MINS should prompt an ECG, with further coronary and cardiac imaging to confirm or exclude primary or secondary MI.^[6]

^[6]

ESC 2022 reports a placebo-controlled trial in 1754 patients (mean age 70 years) with MINS after mainly orthopaedic, general and vascular surgery.^[1] They were randomized to dabigatran 110 mg orally twice daily or placebo within 35 days of MINS.^[1] ESC 2022 reports that the composite major vascular complication outcome occurred in 11% with dabigatran vs. 15% with placebo (HR 0.72, 95% CI 0.55–0.93), and that there was no increase in major bleeding.^[1] The trial it cites is MANAGE, whose abstract (2018) describes an international, randomised, placebo-controlled trial at 84 hospitals in 19 countries that randomly assigned 1754 patients aged at least 45 years who had undergone NCS and were within 35 days of MINS.^[1][29] Its primary efficacy composite of major vascular complications occurred in 11% with dabigatran 110 mg twice daily vs. 15% with placebo (HR 0.72, 95% CI 0.55–0.93).^[29] Its primary safety composite of life-threatening, major and critical organ bleeding occurred in 3% vs. 4% (HR 0.92, 95% CI 0.55–1.53).^[29] ESC 2022 says no single intervention has yet been proven unequivocally beneficial in preventing PMI.^[1] CV risk after NCS seems to stay raised for a ‘vulnerable period’ of 3–5 months.^[1] The 2021 BASEL-PMI MACE report above gives the same 3–5 month vulnerable period: MACE incidence stayed above the presumed baseline rate until day 135 (95% CI 104–163).^[28]

ESC 2022 Recommendation Table 34: peri-operative cardiovascular complications (selected rows)

^[1]

The ESC 2022 text names the high-risk group for surveillance as patients with known CAD, PAD, insulin-dependent diabetes or symptoms suggestive of cardiac disorders undergoing intermediate- or high-risk NCS.^[1] Its key message puts it the same way: high awareness of peri-operative CV complications combined with PMI surveillance in high-risk patients undergoing intermediate- or high-risk NCS.^[1]

^{[1] [6]}

ANZ practice

The ANZCA PG07 guideline (2024) is written to assist doctors with the assessment and preparation of patients being considered for surgery.^[14] It says robust screening and triage tools should be used to facilitate risk assessment and guide optimisation before surgery.^[14] Its consultation includes a medical assessment with relevant history, clinical examination, review of medications and review of relevant investigations.^[14] Further investigations or therapeutic interventions may be needed, and may lead to delay, postponement, reappraisal or even cancellation of the procedure.^[14] Patients should be advised about continuing or stopping any medications that may adversely affect surgery or peri-operative risk.^[14] PG07 says risk assessment and risk stratification, which may involve formal calculation of morbidity and/or mortality, matter in patient discussions and the choice of facility.^[14] If peri-operative risk is equivocal or unacceptable, the need for surgery should be re-evaluated or delayed with the patient and proceduralist.^[14] Its smoking appendix says cessation for at least 4 weeks before surgery has consistently shown improved surgical outcomes.^[14]

The Heart Rhythm New Zealand consensus statement (2024) aims to facilitate safe and effective peri-operative management of patients with cardiac implanted electronic devices during electrosurgery.^[15] Its abstract says electrocautery can damage the generator, inhibit pacing, activate asynchronous pacing and induce ventricular fibrillation.^[15] It calls an active device management plan during electrosurgery critical to minimise these effects.^[15] Only its abstract is held for this topic, so its detailed recommendations are not quoted here. No NHFA/CSANZ guideline on cardiac assessment before NCS was found in the PubMed census for this topic.

Guidelines checked

A row called newer is so among the guidelines checked for this topic:

• ESC material on this page comes from the ESC non-cardiac surgery guideline (2022; Recommendation Tables 1–13, 19–23, 27 and 34, Tables 5 and 6, the Figure 2 and Figure 4 legends and the narrative), with newer ESC rows from the ESC/EACTS valvular heart disease guideline (2025; Section 15 text, key messages, Recommendation Tables 4, 6, 8 and 15), the ESC atrial fibrillation guideline (2024; Recommendation Table 15 and the rate-control and post-operative AF rows) and the ESC cardiomyopathy guideline (2023; Recommendation Table 33); newer ESC text without class rows comes from the ESC hypertension guideline (2024; Section 10.5), and MI definitions from the Fifth Universal Definition of MI (2026; Section 16.5).^{[1][2][4][5][3][6]}
• Trials and cohorts that ESC 2022 describes are also quoted from their own PubMed abstracts beside the guideline wording, and where the two differ both are given.
• A correction to the ESC 2022 guideline was published in 2023: it adds a reference missing from one Section 4.1.1 sentence on the accuracy of risk calculators in vascular surgery, a sentence this page does not use, and the post-correction journal page was compared with the rows used (see the evidence pack).^[16]
• The 2026 AHA/ACC multisociety perioperative guideline (PMID 42804570) is not held as text for this topic, so no US recommendation is given here.
• Superseded and not used as a source for this topic: the 2024 AHA/ACC multisociety perioperative guideline, replaced by the 2026 edition.

Exam pearls

• ESC 2022 Table 5 risk bands: low <1%, intermediate 1–5%, high >5% estimated 30 day risk of CV death, MI and stroke; aortic and major vascular surgery is high risk, and endovascular aortic aneurysm repair is intermediate.^[1]
• ESC 2022 biomarker rows (known CVD, CV risk factors including age ≥65 years, or symptoms suggestive of CVD): hs-cTn before intermediate- and high-risk NCS and at 24 h and 48 h (Class I, Level B); measuring BNP or NT-proBNP before intermediate- and high-risk NCS should be considered (Class IIa, Level B); abnormal BNP ≥35 pg/mL, NT-proBNP ≥125 pg/mL, to be interpreted as quantitative markers of heart failure that also take into account age, sex, obesity and known cardiac disease.^[1]
• ESC 2022 beta-blockers: peri-operative continuation in patients currently receiving them is recommended (Class I, Level B); routine peri-operative initiation is not recommended (Class III, Level A).^[1]
• ESC 2022 pre-operative beta-blocker initiation in advance of high-risk NCS with two or more clinical risk factors (ischaemic heart disease, cerebrovascular disease, renal insufficiency or diabetes mellitus, according to the RCRI), to reduce the incidence of peri-operative MI, may be considered (Class IIb, Level A); its footnote says ideally at least 1 week before surgery, starting with a low dose titrated to a resting heart rate of 60–70 b.p.m. with systolic blood pressure >100 mmHg.^[1]
• ESC 2022 timing after PCI or ACS: delaying elective NCS until 6 months after elective PCI and 12 months after an ACS is recommended (Class I, Level A).^[1]
• ESC 2022 devices: its text says a pre-operative check should have been performed at least once within the 12 months before surgery for a pacemaker and within 6 months for an ICD, in the absence of any malfunction (remote monitoring can also be used; no class or level given).^[1]
• ESC 2022 device re-check: a re-check and necessary reprogramming as soon as possible after the procedure is recommended for all patients with CIEDs reprogrammed before surgery (Class I, Level C).^[1]
• ESC 2022 PMI: an absolute hs-cTn rise of more than the ULN on day 1 or 2 after surgery against the pre-operative value; PMI is largely asymptomatic in about 90% of patients.^[1]

References30ShowHide

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3. [3]Arbelo E, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J, 2023.PMID 37622657
4. [4]Van Gelder IC, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2024.PMID 39210723
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