Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery | Revista Española de Anestesiología y Reanimación (English Edition)

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"apellidos" => "González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0220" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0210" ] 3 => array:3 [ "entidad" => "Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain" "etiqueta" => "d" "identificador" => "aff0215" ] 4 => array:3 [ "entidad" => "Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0220" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] 1 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:1 [ "colaborador" => "Working Group of the CPG" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1625 "Ancho" => 2338 "Tamanyo" => 247395 ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm heart failure." ] ] ] "textoCompleto" => "PresentationThis clinical practice guideline answers to clinical questions concerning this process and is mainly aimed at professionals involved in health care for patients with heart failure before noncardiac surgery to reduce the anaesthetic-surgical risk, with the aim of provide them with appropriate management and treatment of this pathology tools, as well as facilitate coordination between the field of Hospital Care and Surgical Center.This guide is the result of hard work by a group of health professionals from different autonomous communities, specialists in anesthesiology, cardiology, internal medicine, biostatistics, nursing and Methodology of Spain.<elsevierMultimedia ident="tb0005"></elsevierMultimedia><elsevierMultimedia ident="tb0010"></elsevierMultimedia><elsevierMultimedia ident="tb0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>1IntroductionIn 1977, Goldman advised against surgery in patients with heart failure (HF). Nowadays, however, these patients are regularly scheduled for surgery in our hospitals, and the trend is likely to increase in the future. This is because although incidence of cardiac death is falling, the prevalence of ischaemic heart disease, atrial fibrillation (AF), and cardiovascular risk factors such as diabetes mellitus or HTN is increasing, and will no doubt create a greater demand for surgery in these patients in the near future.It is widely accepted that between 1% and 6% of patients undergoing major surgery have heart failure.<a class="elsevierStyleCrossRefs" href="#bib1000">1–50</a> This percentage is expected to increase, because the average age of surgical patients requiring major surgery is rising, and because the prevalence of HF with preserved EF increases with age.Ischaemic heart disease is traditionally associated with increased morbidity and mortality in patients undergoing noncardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib1250">51–54</a> However, we now know that HF is the primary intraoperative risk factor in cardiovascular disease patients undergoing noncardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib1050">11,24,31,32,42,55–58</a>Despite its undoubted importance, HF is frequently underestimated, possibly due to epidemiological reasons. Let us not forget that HF is the third cause of death (15%) from cardiovascular disease after ischaemic heart disease and cerebrovascular disease, which together are responsible for 60% of deaths. The real importance of HF, however, is underestimated, because many patients that die from ischaemic heart disease or cerebrovascular disease also have HF, which to a certain extent contributes to their death.<a class="elsevierStyleCrossRef" href="#bib1290">59</a>References:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0010">-Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845–50.</li><li class="elsevierStyleListItem" id="lsti0015">-Mangano DT. Perioperative cardiac morbidity. Anesthesiology. 1990;72:153–84.</li><li class="elsevierStyleListItem" id="lsti0020">-Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischaemia Research Group. N Engl J Med. 1996;335:1713–20.</li><li class="elsevierStyleListItem" id="lsti0025">-Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.</li><li class="elsevierStyleListItem" id="lsti0030">-Wiklund RA, Stein HD, Rosenbaum SH. Activities of daily living and cardiovascular complications following elective, noncardiac surgery. Yale J Biol Med. 2001;74:75–87.</li><li class="elsevierStyleListItem" id="lsti0035">-Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105:1257–67.</li><li class="elsevierStyleListItem" id="lsti0040">-Aurigemma GP, Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med. 2004;351:1097–105.</li><li class="elsevierStyleListItem" id="lsti0045">-Hernandez AF, Whellan DJ, Stroud S, Sun JL, O’Connor CM, Jollis JG. Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 2004;44:1446–53.</li><li class="elsevierStyleListItem" id="lsti0050">-Gonseth J, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J. 2004;25:1570–95.</li><li class="elsevierStyleListItem" id="lsti0055">-McMurray JJ, O’Meara E. Treatment of heart failure with spironolactone – trial and tribulations. N Engl J Med. 2004;351:526–8.</li><li class="elsevierStyleListItem" id="lsti0060">-Mangano DT. Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth. 2004;18:1–6.</li><li class="elsevierStyleListItem" id="lsti0065">-Flather MD, Shibata MC, Coats AJ, Van Veldhuisen DJ, Parkhomenko A, Borbola J, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J. 2005;26:215–25.</li><li class="elsevierStyleListItem" id="lsti0070">-Hunt SA, ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005;46:e1–82.</li><li class="elsevierStyleListItem" id="lsti0075">-Bhatia RS, Tu JV, Lee DS, Austin PC, Fang J, Haouzi A, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med. 2006;355:260–9.</li><li class="elsevierStyleListItem" id="lsti0080">-Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F, et al. Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006;27:1341–81.</li><li class="elsevierStyleListItem" id="lsti0085">-Boersma E, Kerta I MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, Schinkel AF, et al. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med. 2005;118:1134–41.</li><li class="elsevierStyleListItem" id="lsti0090">-Don Poldermans et al., Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur. J. Anaesthesiol. 2010;27:92–137.</li></ul>2Scope and objectives2.1ObjectivesThis clinical practice guideline (CPG) is intended to serve as a tool to reduce uncertainty and variability in the detection, treatment and control of heart failure patients requiring noncardiac surgery. The aim of this CPG is to:<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0095">2.1.1.Review current practice in connection with the clinical problem and make a series of evidence-based recommendations (Table of General Recommendations).</li><li class="elsevierStyleListItem" id="lsti0100">2.1.2.Draw up a strategy for reducing anaesthesia and surgical risk in these patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Risk reduction, therefore, will be the central theme of these recommendations.<elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0105">2.1.3.Unlike other clinical guidelines, this CPG will consider intra- and postoperative manoeuvres and treatment to be equally important as preoperative therapy and risk assessment.</li><li class="elsevierStyleListItem" id="lsti0110">2.1.4.Facilitate decision-making in pre-, intra-, and postoperative management of HF patients requiring, or having undergone, noncardiac surgery.</li><li class="elsevierStyleListItem" id="lsti0115">2.1.5.Provide patients and carers with useful information on evidence-based interventions that can facilitate shared decision-making and enable them to become actively involved in the process of care.</li></ul>2.2Target populationThis guideline is aimed at any adult individual with risk factors or a diagnosis of heart failure (HF). The term HF will be used through this clinical practice guideline. HF encompasses both primary heart failure and secondary heart failure treated in the same way as primary HF. It will not deal with specific management of secondary causes leading to HF. The guideline does not include the paediatric population because the general characteristics of HF (causes, treatment and evolution) differ in these patients.2.3Clinical areas included in the guidelineThis guideline addresses:<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0120">•Overview of HF<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0125">∘Diagnosis of HF</li><li class="elsevierStyleListItem" id="lsti0130">∘Management of HF</li></ul></li><li class="elsevierStyleListItem" id="lsti0135">•Preoperative risk reduction in HF patients scheduled for noncardiac surgery.<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0140">∘Risk assessment and risk indices</li><li class="elsevierStyleListItem" id="lsti0145">∘Alternative therapies</li><li class="elsevierStyleListItem" id="lsti0150">∘Preoperative revascularisation</li><li class="elsevierStyleListItem" id="lsti0155">∘Arrhythmia</li><li class="elsevierStyleListItem" id="lsti0160">∘Implantable devices and surgery</li></ul></li><li class="elsevierStyleListItem" id="lsti0165">•Intraoperative risk reduction in HF patients scheduled for noncardiac surgery.<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0170">∘Monitoring</li><li class="elsevierStyleListItem" id="lsti0175">∘Haemodynamic optimisation</li><li class="elsevierStyleListItem" id="lsti0180">∘Conditioning and its role in risk reduction</li><li class="elsevierStyleListItem" id="lsti0185">∘Remote ischaemic conditioning</li><li class="elsevierStyleListItem" id="lsti0190">∘Pharmacological conditioning</li></ul></li><li class="elsevierStyleListItem" id="lsti0195">•Risk-reducing anaesthetic techniques</li><li class="elsevierStyleListItem" id="lsti0200">•Postoperative risk reduction strategy<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0205">∘Pain</li><li class="elsevierStyleListItem" id="lsti0210">∘Hypothermia and hypoxia</li><li class="elsevierStyleListItem" id="lsti0215">∘Acute postoperative HF<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0220">•Postoperative hypotension/hypertension</li><li class="elsevierStyleListItem" id="lsti0225">•Postoperative low cardiac output syndrome</li><li class="elsevierStyleListItem" id="lsti0230">•Acute heart failure, left ventricular failure, and cardiogenic pulmonary oedema</li><li class="elsevierStyleListItem" id="lsti0235">•Cardiogenic shock</li><li class="elsevierStyleListItem" id="lsti0240">•Myocardial ischaemia and acute myocardial infarction</li></ul></li></ul></li><li class="elsevierStyleListItem" id="lsti0245">•Specific pathologies in heart failure patients<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0250">∘Valve disease</li><li class="elsevierStyleListItem" id="lsti0255">∘Hypertension</li><li class="elsevierStyleListItem" id="lsti0260">∘Right ventricular failure. Right-sided heart failure</li><li class="elsevierStyleListItem" id="lsti0265">∘Pulmonary arterial hypertension</li><li class="elsevierStyleListItem" id="lsti0270">∘Heart failure and sepsis</li><li class="elsevierStyleListItem" id="lsti0275">∘Heart failure and renal replacement therapy</li><li class="elsevierStyleListItem" id="lsti0280">∘Mechanical ventilation in heart failure patients</li></ul></li></ul>This guideline DOES NOT address:<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0285">•Structural heart disease not leading to HF, and management of these diseases in surgical patients</li><li class="elsevierStyleListItem" id="lsti0290">•Coronary disease not leading to HF, and management of these diseases in surgical patients</li><li class="elsevierStyleListItem" id="lsti0295">•Other cardiovascular disorders not leading to HF, and management of these disorders in surgical patients</li><li class="elsevierStyleListItem" id="lsti0300">•Congenital coronary disease leading or not leading to HF in surgical patients</li><li class="elsevierStyleListItem" id="lsti0305">•Evaluation of the use of resources and the cost of treatment</li></ul>2.4Target healthcare areaThis guideline is for use in the Spanish National Health System.2.5Target usersThis guideline is aimed at specialists in anaesthesiology and critical care, cardiology, nursing and internal medicine involved in the care of heart failure patients scheduled for noncardiac surgery.3MethodologyThis clinical practice guideline has been drawn up in accordance with the Methodology Handbook for Developing Clinical Practice Guidelines (2007). The “Quality of evidence and grades of recommendation” system mentioned earlier in this guideline will be explained in more detail. Additional information on the methodology used to develop the CPG is available at <a href="http://www.sedar.es/">www.sedar.es</a> (critical appraisal tools for the studies selected and summary of findings tables).Generally speaking, the work was carried out in the following stages:3.1Creation of the task forceThe group in charge of drawing up the guideline is formed of specialists in the fields of anaesthesiology and critical care, internal medicine, intensive care, cardiology and nursing, and a specialist in methodology from the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy.3.2Formulation of clinical questionsThe questions were formulated according to the PICO (population, intervention, comparison and outcome) format, and discussed during a meeting of the members of the task force. During the meeting, the group arranged the CPG into different sections and prioritised the questions on the basis of the objectives, scope, target population, clinical area and target users of the CPG.The benefits and safety of the interventions included in the guideline were evaluated by prioritising the key outcomes sought by patients. In terms of benefit, the main outcome was a successful intervention (successful surgery with no heart failure-related complications); in terms of safety, it was the adverse effect of the intervention. Some questions included other, more specific key outcomes.3.3Literature searchA preliminary search was made for CPGs, systematic reviews (SR) and other key summaries, as well as health technology assessment reports, in the scientific literature. At this stage, the following online databases were searched:<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0310">•NHS Evidence</li><li class="elsevierStyleListItem" id="lsti0315">•Cochrane Database of Systematic Reviews (The Cochrane Library)</li><li class="elsevierStyleListItem" id="lsti0320">•Database of Abstracts of Reviews of Effects (DARE)</li><li class="elsevierStyleListItem" id="lsti0325">•Health Technology Assessment (HTA) Database</li><li class="elsevierStyleListItem" id="lsti0330">•MEDLINE (through PubMed)</li></ul>During the second stage, databases were searched for specific studies that would contribute updated information to existing relevant SRs and answer questions not addressed by studies retrieved in the first stage. Randomised clinical trials (RCS) and observational studies (risk factor and screening issues) were mainly retrieved. The foregoing searches were conducted in MEDLINE and The Cochrane Central Register of Controlled Trials.A specific search was made of the MEDLINE (Pubmed) database for information for the values and preferences section.The searches performed were not limited by language. Documents published up to and including 30 September 2013 (<a class="elsevierStyleCrossRef" href="#sec0455">Annex 1</a>: search strategies).3.4Study selection and evaluation of the quality of the evidencePrior to selection, the titles and abstracts of studies on the benefits and safety of surgery were screened for relevance to the questions to be addressed in the CPG. The full text of studies considered relevant was then evaluated for quality before being included in the CPG (additional material available at <a href="http://www.sedar.es/">www.sedar.es</a>: evaluación de la calidad de los estudios individuales de la GPC [only in Spanish]). Only studies of the highest quality reporting target outcomes were chosen (low risk of bias). Systematic reviews, followed by randomised clinical trials, were prioritised. In the case of randomised clinical trial, the summary of findings (meta-analysis) was included wherever possible.The quality of the evidence presented was evaluated according to the criteria established by the international GRADE group (Grading of Recommendations of Assessment Development and Evaluations) (Alonso-Coello, 2013). The quality of the available body of evidence was evaluated for each outcome included in each clinical question. The following factors were taken into account: risk of bias, consistency of findings from different studies, availability of direct evidence, accuracy of effect estimates, and publication bias. In the case of observational studies, the following factors were also taken into account: effect sizes, dose–response correlation, impact of confounding factors on results. Following the evaluation process, the quality of evidence for each outcome was ranked as high, moderate, low or very low.It is interesting to note that for most of the questions in the CPG no information on the effect of interventions on disease progression was found. Most of the studies identified evaluated myocardial ischaemia, and not heart failure, as a measure of the effectiveness of interventions designed to treat heart disease. Ischaemia, therefore, is a surrogate measure for disease progression and associated complications; being an indirect measurement, therefore, the quality of this outcome was relatively low, while that of HF was relatively high.With respect to patient values and preferences, studies retrieved from the × were initially screened by title and abstract, and those that analysed useful health status values in heart failure patients were chosen. Systematic reviews were initially prioritised, followed by individual studies. A narrative synthesis was made of the main findings.3.5Formulation of recommendationsRecommendations based on the summary of the available evidence for each clinical question, were formulated according to the GRADE approach. To determine the direction (for or against an intervention) and strength (Strong or weak) of recommendations, the overall quality of available evidence, the risk-benefit ratio of each procedure evaluated, and patient values and preferences were weighed up.Whenever the effect of a particular intervention on disease progression was not reported, it was estimated on the basis of its effect during surgery. These calculations were based on the risk of progression established in the “Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery” drafted by the The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). European Journal of Anaesthesiology 2010, 27:92–137. This CPG estimates the risk of cardiac events and mortality (as a percentage) according to the type of surgery performed. Despite being an approximation, this estimator was considered to more closely reflect the real effect of interventions designed to reduce the risk in question following surgery in HF patients.<elsevierMultimedia ident="tb0020"></elsevierMultimedia>Evidence summaries and their associated recommendation were submitted to members of the work force for consideration. Decisions were taken on the basis of the depth and relevance of the research and the findings reported. Following this, the whole group met to discuss all the recommendations.3.6External reviewThe guideline was submitted to a multidisciplinary team for external review. This team was made up of professionals from the Spanish Society of Cardiology, the Spanish Society of Anaesthesiology, Intensive Care and Pain Therapy, the Spanish Society of Internal Medicine, the Spanish Association of Surgical Nursing and the Spanish Surgery Nurse Society.3.7UpdatesThe guideline will be updated every three years, or sooner if new scientific evidence emerges that would change any of the recommendations made. Updates will be made to the online version of the guideline, available on <a href="http://www.sedar.es/">www.sedar.es</a>.References<ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0335">-Grupo de trabajo sobre GPC. Elaboración de Guías de Práctica Clínica en el Sistema Nacional de Salud. Manual Metodológico. Madrid: Plan Nacional para el SNS del MSC. Instituto Aragonés de Ciencias de la Salud-I+CS; 2007. Guías de Práctica Clínica en el SNS: I+CS N° 2006/0I.</li><li class="elsevierStyleListItem" id="lsti0340">-Alonso-Coello P, Rigau D, Sanabria AJ, Plaza V, Miravitlles M, Martinez L. Quality and strength: The GRADE system for formulating recommendations in clinical practice guidelines. Arch Bronconeumol. 2013;49(6):261–7.</li><li class="elsevierStyleListItem" id="lsti0345">-Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z, et al. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007;114:1965–72.</li></ul>4Heart failure<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The incidence and prevalence of HF is extremely high in clinical practice, and for this reason many surgical patients present this comorbidity. According to estimates, 20% of individuals aged over 40 years in the United States are at risk for this disease.<a class="elsevierStyleCrossRef" href="#bib1295">60</a>HF affects between 1% and 2% of the world's population; incidence is as high as 10–20% in the over-75 group, and it accounts for approximately 2% of healthcare spending. HF patients constitute 10% of the hospital population, and patients with advance HF mean survival is shorter than in many types of cancer. Although survival is improving, 50% of patients do not survive longer that 5 years following diagnosis.<a class="elsevierStyleCrossRefs" href="#bib1095">20,46,48</a>Ischaemic heart disease and hypertension are responsible for 70% of chronic HF cases. These are followed by congenital valve defects (10%), cardiomyopathies (10%), and miscellaneous conditions, including arrhythmia, conduction disturbances, conditions causing increased cardiac output (anaemia, sepsis, Paget's disease, thyrotoxicosis, drug therapy, use of drugs such as cocaine), and diseases such as amyloidosis and sarcoidosis.The American College of Cardiology and the American Heart Association (ACC/AHA) define HF as a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood, but that ultimately affects all organs and systems. Tiredness, fatigue, dyspnoea, fluid retention, which may lead to pulmonary congestion and peripheral oedema are the main symptoms of HF, as shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 2</a>.<a class="elsevierStyleCrossRefs" href="#bib1060">13,48</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The ACC/AHA proposed dividing HF into four stages: A–D (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 3</a>), according to the extent to which the patient's physical activity is affected. This functional classification is a valuable prognostic tool, and can be used as a criterion in the choice of certain therapeutic decisions. It is used to evaluate patient follow-up and response to treatment. This system of classification differs from that used by the New York Heart Association (NYHA), which also divides HF into four stages, but bases these on structural changes and symptoms.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Since HF is a syndrome, this classification has become popular due to its obvious practical advantages. However, it also has some major drawbacks, including lack of standardisation or frequent fluctuations in symptoms not associated with major changes in diet or therapy. Improvements, meanwhile, are at times associated with therapeutic changes that must be maintained in the long term, irrespective of changes in the patient's functional capacity. It is essential to determine the functional capacity of HF patients in order to evaluate their preoperative level of risk.<a class="elsevierStyleCrossRef" href="#bib1300">61</a>In two types of heart disease, namely, coronary disease and valve disease, pathogenesis must be correctly diagnosed, since this will greatly affect the prognosis.4.1Overview of the importance of systolic and diastolic heart failure in surgical patients<elsevierMultimedia ident="tb0030"></elsevierMultimedia>Physicians usually distinguish between systolic and diastolic HF, although the difference is not as clear as it would initially appear.<a class="elsevierStyleCrossRefs" href="#bib1030">7,46,48,62–65</a> Systolic and diastolic HF should not be considered different entities,<a class="elsevierStyleCrossRef" href="#bib1325">66</a> and most HF patients show both dysfunctions both at rest and with exercise.Diastolic HF occurs when patients present signs and/or symptoms of HF with a left ventricular ejection fraction (LVEF) higher than 40–50%, although opinions differ on the cut-off point for preserved LVEF; a left ventricular end diastolic pressure higher than 18mmHg is consistent with significant heart failure, and when restrictive diastolic dysfunction occurs, there is a risk of decompensation with the slightest fluid intake or overload.<a class="elsevierStyleCrossRef" href="#bib1330">67</a>Within this patient group, it is important to consider those with asymptomatic diastolic dysfunction, which can worsen as a result of noncardiac surgery.Systolic HF is defined as an entity presenting symptoms of HF with depressed LVEF.Prognosis for HF is highly complex due to widely differing pathogenesis and comorbidities. Depressed LVEF, in other words systolic HF, has the worse prognosis. However, recent studies, albeit in medical patients not requiring surgery, have shown that prognosis is similar for systolic and diastolic patients.<a class="elsevierStyleCrossRef" href="#bib1065">14</a>Prognosis for survival in patients undergoing high or intermediate risk noncardiac or cardiac surgery is significantly worse in patients with depressed LVEF.<a class="elsevierStyleCrossRefs" href="#bib1130">27,35,69</a> This is a key factor in noncardia surgery patients, and one that not emphasised enough in most guidelines. It is definitely an element to consider in risk reduction strategies.4.2Diagnosis of heart failure patients<elsevierMultimedia ident="tb0035"></elsevierMultimedia>All guidelines published to date devote considerable space to the diagnosis of HF. Patients with congestive heart failure (CHF) are usually diagnosed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). If clinical features suggestive of CHF emerge while taking a medical history in an undiagnosed patient, a preoperative cardiac evaluation must be ordered.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The main diagnostic texts in a patient with suspected HF are electrocardiogram (ECG), chest X-ray, and most importantly, echocardiogram (echo). The combination of these three techniques will, in most cases, establish a diagnosis of HF, as shown in the algorithm in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.Chest X-ray can detect cardiomegaly and pleural effusion, but is of limited use in diagnosing HF. It is, however, a useful differential diagnosis tool in respiratory diseases. It can show signs of pulmonary congestion, pleural effusion or enlargement of the cardiac silhouette. However, it should be borne in mind that patients with severe diastolic dysfunction do not show signs of cardiomegaly.<a class="elsevierStyleCrossRefs" href="#bib1225">46,48</a>Echo gives real-time, non-invasive information about chamber size, systolic and diastolic ventricular function, valvular function, thickness and mobility of ventricular walls, and signs of pulmonary arterial hypertension (PH).<a class="elsevierStyleCrossRef" href="#bib1225">46</a> This information is critical for determining the level of control of the prescribed medication.Since the signs and symptoms of HF are unspecific, determination of natriuretic peptides (BNP, Nt-Pro BNP), which are released during interventricular septal thickening, can help in the diagnosis of HF patients. Peptide levels should be determined before performing echocardiography (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), since normal levels should rule out HF.The usefulness of this test in the preoperative workup,<a class="elsevierStyleCrossRefs" href="#bib1145">30,70</a> however, is widely debated and has yet to be clearly defined. In geriatric patients, or patients with kidney failure, BNP levels can be elevated even in the absence of HF symptoms, while in obese patients, BNP levels can be falsely low. Low serum natriuretic peptide levels rule out HF but not the possibility of structural heart disease.Normal natriuretic peptide levels in untreated patients all but rules out heart disease, and consequently the need for an echo. The usual natriuretic peptide cutoff levels for excluding HF are 100pg/ml for BNP and 300pg/ml for NT-Pro BNP.<a class="elsevierStyleCrossRef" href="#bib1350">71</a> In the elderly and in patients with advanced kidney failure, BNP levels vary, as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.Two meta-analyses on postoperative variations in BNP in patients with HF undergoing noncardiac surgery have recently been published.<a class="elsevierStyleCrossRefs" href="#bib1355">72,73</a> Both studies found that increased natriuretic peptide levels post-surgery are associated with increased mortality at 30 and 180 days, and increased risk of AMI.4.3Heart failure management<elsevierMultimedia ident="tb0040"></elsevierMultimedia>In this guideline, we will not dwell on management of HF, since this has already been discussed in several medical texts (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a>). Instead, we will focus on the capacity of each type of HF medication to reduce risk in patients scheduled for surgery, because good HF management should not only treat symptoms, but also prevent disease progression and diminish the risk of morbidity and mortality in surgical patients.<a class="elsevierStyleCrossRefs" href="#bib1040">9,46,48,74–76</a><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>The main changes in HF treatment in the most recent European and US guidelines with respect to former recommendations are: expansion of the indication for mineralocorticoid (aldosterone) receptor antagonists; new indication for the sinus node inhibitor ivabradine, such as in class NYHA II-IV chronic heart failure, systolic dysfunction, in patients in normal sinus rhythm and ≥75bpm, in association with standard treatment including betablockers, or when these are contraindicated or poorly tolerated; expansion of the indication for implantable cardioverter defibrillators (ICD); cardiac-resynchronisation therapy; new information on the role of coronary revascularization in HF; recognition of the growing use of ventricular assist devices; and the emergence of transcatheter valve interventions.<a class="elsevierStyleCrossRefs" href="#bib1225">46,48,77</a><elsevierMultimedia ident="tb0045"></elsevierMultimedia>As mentioned previously, although ischaemic heart disease is usually associated with increased perioperative morbidity and mortality, congestive HF is in fact the main perioperative risk factor in patients with cardiovascular disease undergoing noncardiac surgery.<a class="elsevierStyleCrossRef" href="#bib1250">51</a>An increasingly common added difficulty arises when the patient's asymptomatic or compensated myocardial dysfunction becomes symptomatic or decompensated due to the stress of surgery.After establishing a diagnosis of HF, it is important to also establish an aetiological diagnosis, in case a new medical or surgical treatment can be found for the causative pathology. Valve disease, such as aortic stenosis, is frequently corrected before performing other surgery. The same is true of ischaemic heart disease.4.4Risk evaluation in heart disease patients undergoing noncardiac surgeryStrictly speaking, the term heart failure should not be used in association with surgical patients, because HF refers to two clearly differentiated clinical situations: HF with preserved LVEF or HF with depressed LVEF. As mentioned previously, HF with depressed LVEF is a more high-risk situation.<a class="elsevierStyleCrossRefs" href="#bib1130">27,35,68–71</a>Estimates suggest that 0.3% of patients undergoing noncardiac surgery die from postoperative cardiovascular causes. In the case of bypass surgery, the mortality rate is as high as 2%, in other words, seven times higher than noncardiac procedures.<a class="elsevierStyleCrossRef" href="#bib1385">78</a> Boersma,<a class="elsevierStyleCrossRef" href="#bib1265">54</a> in a cohort of over 100,000 patients undergoing noncardiac surgery, reported a mortality rate of 1.7%, or which 0.5% was attributed to cardiovascular causes. In the DECREASE studies, 3.5% of intermediate or high-risk surgical patients died from cardiac complications.<a class="elsevierStyleCrossRef" href="#bib1390">79</a> The POISE<a class="elsevierStyleCrossRef" href="#bib1395">80</a> study reported an overall mortality rate of 2.7%, of which 1.6% was from cardiovascular causes, with a 4.4% rate of non-fatal myocardial infarction.Although experts unanimously agree that CHF is a risk factor in patients undergoing noncardiac surgery, it is important to remember that complications arising from this pathology depend not only on the condition of the heart, but also on the type of surgery performed, the technique used, the level of urgency, and the perioperative treatment given.<a class="elsevierStyleCrossRef" href="#bib1050">11</a>Surgical risk is usually stratified into three levels, shown in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 5</a>.<a class="elsevierStyleCrossRefs" href="#bib1025">6,32</a> Similarly, cardiological risk is divided into three levels: low, intermediate and high, shown in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 6</a>.<a class="elsevierStyleCrossRefs" href="#bib1025">6,32</a><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia>Emergency surgery, in other words surgery that cannot be delayed, is always an added risk factor. The risk of emergency noncardiac surgery is estimated to be between two to five time higher than scheduled procedures.<a class="elsevierStyleCrossRef" href="#bib1005">2</a> Because of this high level of risk, it is best to delay urgent (within 48h), or semi-elective (between 48h and 7 days after diagnosis) noncardiac surgery. The delay between diagnosis and surgery should be used to evaluate cardiac risk based on existing evidence whenever needed (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>) and in patients subject to preoperative haemodynamic optimisation strategies that could change the prognosis.<a class="elsevierStyleCrossRefs" href="#bib1400">81,82</a><elsevierMultimedia ident="tbl0045"></elsevierMultimedia>The choice of surgical technique and when to perform the surgery, together with the anaesthetic techniques to be discussed further on, are of paramount importance. Preoperative anaemia is associated with increased mortality,<a class="elsevierStyleCrossRefs" href="#bib1365">74–76,83</a> and as far as possible should be treated without blood transfusion, since this also increases risk in surgical patients.<a class="elsevierStyleCrossRef" href="#bib1415">84</a>4.4.1Cardiac assessment in heart failure patients requiring noncardiac surgery. Functional capacity. Risk indicesIt is important to evaluate the patient's functional capacity as part of the perioperative cardiac risk evaluation. Functional capacity can be evaluated on the basis of the patient's capacity to perform activities of daily living. Functional capacity is usually measured in metabolic equivalents (MET): 1 MET is the basal metabolic rate, while climbing two flights of stairs requires 4 METs, and strenuous exercise requires more than 10 METs. According to some authors, patients that are incapable of climbing two flights of stairs (<4 METs) have a greater risk of cardiac complications. However, the relationship is weak. There is ample evidence, however, that prognosis improves in parallel with improved functional capacity.<a class="elsevierStyleCrossRefs" href="#bib1020">5,61,85</a>Several authors have explored the various cardiac assessment tests used.<a class="elsevierStyleCrossRef" href="#bib1080">17</a> Focussed cardiac assessment should only be performed in patients included in <a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>. The some focussed cardiac assessment tests have been graded according to recommendation and level of evidence. Cardiac risk should be combined with that of the surgery itself, as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The use of risk indexes is widely debated. Goldman's Index<a class="elsevierStyleCrossRef" href="#bib1000">1</a> was the first to gain prominence, although it has been shown to have serious limitations. The indexes developed by Detsky<a class="elsevierStyleCrossRef" href="#bib1425">86</a> and Lee<a class="elsevierStyleCrossRef" href="#bib1015">4</a> are the most widely used nowadays. European guidelines<a class="elsevierStyleCrossRef" href="#bib1190">39</a> recommend Lee's index to stratify perioperative risk, despite its obvious shortcomings, including its inability to identify high-risk patients.<a class="elsevierStyleCrossRef" href="#bib1265">54</a> Lee's index comprises six risk factors, five of which depend on the patient's medical history: history of ischaemic heart disease, cerebrovascular disease, heart failure, insulin-dependent diabetes mellitus and kidney function impairment. The sixth factor is high-risk surgery. The Erasmus system performs better in terms of predicting and discriminating risk, since it added age and a more detailed classification of surgical procedures to the equation.<a class="elsevierStyleCrossRef" href="#bib1265">54</a>Twelve-lead ECG is unreliable, and many experts consider it redundant in patients with no cardiovascular risk factors. Stress testing is included in what is called focussed cardiological assessment protocols (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>). Stress testing should only be carried out in certain surgical patients.<a class="elsevierStyleCrossRef" href="#bib1155">32</a>Transthoracic echo (TTE) has become the gold standard preoperative evaluation; it has few complications, and gives a highly specific and sensitive diagnosis. TTE should not be routinely performed, although it should be included in focussed cardiological assessment protocols. The benefit of TTE in patients with known, but stable, heart disease is unclear,<a class="elsevierStyleCrossRefs" href="#bib1155">32,39</a> and in this group of patients it should mainly be used to determine whether any clinical changes have occurred. This “new” symptomatology that changes a patient's basal status is a definitive indication for TTE. The “new” symptoms to be carefully evaluated are angina and signs of HF.Holter monitoring, myocardial perfusion scintigraphy and coronary angiography are rarely indicated in these patients, and only as part of a focussed cardiological assessment.4.4.2Cardiopulmonary exercise testingCardiopulmonary exercise testing, in which inhaled and exhaled gases are measured by means of a mask or nose prongs while the patient uses a static cycle or treadmill, gives a more reliable measurement of cardiopulmonary function and oxygen uptake. Cardiopulmonary exercise testing, although not widely used, helps stratify risk and optimise perioperative treatment in lung resection.<a class="elsevierStyleCrossRefs" href="#bib1120">25,87</a>4.5Risk limitation through chronic pharmacologic therapy for heart failure<elsevierMultimedia ident="tb0050"></elsevierMultimedia>In these patients, evaluation and optimisation targets vary according to functional status. Patients with good functional status (NYHA 1) will not require diagnostic tests other than those included in standard preoperative evaluation protocols.<a class="elsevierStyleCrossRef" href="#bib1190">39</a>In patients with compensated HF (NYHA I–II) undergoing surgery with a risk factor of <1%, medication should be maintained up to the day of the intervention. Therapeutic measures should be optimised to try to improve the functional status of patients with symptoms of HF (NYHA II–IV), with a confirmed and evaluated diagnosis according to the algorithm shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, who require surgery with a <1% risk.<a class="elsevierStyleCrossRefs" href="#bib1225">46,48</a>As a general rule, the functional status of patients showing symptoms of HF with moderate exercise must be improved by adjusting their therapy. Several studies have been published on the benefits of natriuretic peptide testing to determine the severity of HF versus clinical signs. Although not supported by clear scientific evidence, these studies suggest that NT-Pro BNP levels of >2000pg/ml (above all in patients<75 years) predict a high risk of cardiac decompensation.NT-Pro BNP levels <400pg/ml, meanwhile, are associated with a low risk.<a class="elsevierStyleCrossRefs" href="#bib1360">73,88</a>These results suggest that, except in the most urgent surgery, NT- Pro BNP levels should remain below 2000pcg/ml and as close as possible to 400pg/ml, particularly in interventions with a risk rate of >1%. <a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a> shows the treatment schedule for CHF, together with evidence for limiting risk using the usual medication given to these patients.<a class="elsevierStyleCrossRefs" href="#bib1110">23,30,38,48</a>Perioperative administration of beta-blockers, ACE inhibitors, statins, and aspirin significantly reduces intrahospital mortality in patients with depressed left ventricular function undergoing bypass surgery.<a class="elsevierStyleCrossRef" href="#bib1390">79</a> CHF treatment guidelines recommend administration of ACE inhibitors, or angiotensin receptor blockers in case of intolerance, with beta-blockers as first line treatment in HF to improve morbidity and mortality. This treatment is important in HF patients, and essential in patients with LVEF<40–45%.<a class="elsevierStyleCrossRefs" href="#bib1110">23,48,89</a>Other drugs, however, can exacerbate the symptoms of HF or cause heart disturbances. These include corticosteroids, calcium-channel blockers, class I and II antiarrhythmic agents, minoxidil, amphetamines, dihydropyridines, metformin, anagrelide, cilostazol, carbamazepine, clozapine, ergot alkaloids, pergolide, tricyclic antidepressants, B2 agonists, itraconazole and infliximab. Non-selective nonsteroidal anti-inflammatory drugs (NSAIDS) can worsen symptoms.<a class="elsevierStyleCrossRef" href="#bib1445">90</a>4.5.1Beta-blockersBeta-blockers are perhaps the most effective drugs for reducing morbidity and mortality in HF patients. Curiously, few studies have been published on this subject. The main aim of perioperative administration of beta-blockers is to reduce myocardial oxygen uptake by reducing heart rate. This prolongs diastolic filling time and reduces contractility.<a class="elsevierStyleCrossRef" href="#bib1450">91</a> Recent studies, however, have rekindled the old controversy over the use of beta-blockers in noncardiac surgery.<a class="elsevierStyleCrossRef" href="#bib1455">92</a>Preoperative suspension of beta-blockers in HF patients is not justified, and if they have not previously been given but are indicated, they should be started. In the case of urgent surgery, they should be administered intravenously immediately before surgery and continued in the postoperative period. Mangano<a class="elsevierStyleCrossRef" href="#bib1010">3</a> published a study on the efficacy of beta-blockers in reducing long-term mortality, and these findings were later confirmed by several other authors.<a class="elsevierStyleCrossRefs" href="#bib1385">78,80,93</a> Recently, Andersson confirmed the prognostic value of beta-blockers in patients with ischaemic HF undergoing noncardiac surgery in a study in over 700,000 patients.<a class="elsevierStyleCrossRef" href="#bib1465">94</a>Initially, beta-blockers should be continued in patients already receiving this therapy. They should be given to high-risk patients and patients with ischaemic heart disease at least one week before surgery.In patients with decompensated HF, beta-blockers can be down-dosed or temporarily suspended,<a class="elsevierStyleCrossRef" href="#bib1110">23</a> and even surgery should be suspended until treatment has been optimised. There are several contraindications for beta blockers, the most important being: asthma, known hypersensitivity to the active ingredient, sinus bradycardia, cardiogenic shock, hypotension, metabolic acidosis, serious peripheral artery disease, second or third degree atrioventricular block, sick sinus syndrome, untreated phaeochromocytoma and manifest heart failure. These contraindications should be borne in mind, although beta-blockers are not contraindicated in intermittent claudication.<a class="elsevierStyleCrossRefs" href="#bib1445">90–95</a>When surgery can be delayed, beta-blocker therapy should start from one week to one month before the intervention. This rules out urgent, non-delayable surgery. Treatment should start with low-dose beta blockers, which can then be adjusted in the period leading up to the intervention until the patient has a resting heart rate of 60–70bpm, and systolic pressure is higher than 00mmHg.4.5.2NitratesThe effect of nitrates is well known, but the benefits of routine use of these drugs is unclear. Nitrates reduce perioperative myocardial ischaemia in patients with stable angina receiving intravenous nitroglycerine during noncardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib1475">96,97</a> Nitrates do not reduce mortality or prevent acute myocardial infarction. Perioperative use of nitroglycerine can alter haemodynamic parameters, since it can reduce preload and cause hypotension and tachycardia.4.5.3StatinsSystematic used of statins in surgical patients at cardiovascular risk is becoming increasingly important. Patients with atherosclerosis should be given preoperative statins for secondary prevention, independent of the type of surgery,<a class="elsevierStyleCrossRefs" href="#bib1085">18,98,99</a> since these agents have been shown to significantly reduce complications.<a class="elsevierStyleCrossRefs" href="#bib1485">98–102</a>Statins are equally beneficial, irrespective of the pathogenesis of HF and cholesterol levels.<a class="elsevierStyleCrossRef" href="#bib1005">2</a>They are not, however, entirely free from side effects, and the risk of myopathy and rhabdomyolysis in surgical patients is of considerable concern, above all in those with impaired kidney function. If myopathy is not detected, and statins are maintained, there is a risk of rhabdomyolysis and acute kidney failure,<a class="elsevierStyleCrossRef" href="#bib1500">101</a> however, suspension of statins worsens the prognosis.<a class="elsevierStyleCrossRef" href="#bib1510">103</a> Administration of statins in surgical patients is hindered by the absence of an intravenous formulation of the drug. This can be compensated in part with long half-life or slow-release statins, such as extended-release rosuvastatin, atorvastatin and fluvastatin, which prolong the effect of the drug.4.5.4DiureticsDiuretics can be used to control symptoms, and should be given to HF patients with signs and symptoms of congestion. In patients with difficult-to-control symptoms (NYHA III or IV) or LVEF<35%, association with an aldosterone receptor antagonist should be considered.There is no evidence to show that loop diuretics can affect mortality, although potassium-sparing diuretics have been shown to be beneficial in this regard. Loop diuretics such as furosemide and torasemide, being more effective, should be used in patients with advanced disease and also to treat exacerbations, while thiazide diuretics such as chlorthalidone and hydrochlorothiazide should be given in less advanced stages. Kidney function must always be considered when administering these drugs.<a class="elsevierStyleCrossRefs" href="#bib1225">46,48</a>Torasemide is associated with less urine output than furosemide, and is an aldosterone antagonist. Oral diuretics are poorly absorbed by patients with intestinal oedema, and in these case they should be administered intravenously. Thiazides are ineffective when creatinine clearance is less than 30%, and it is important to bear in mind their “therapeutic ceiling”.<a class="elsevierStyleCrossRef" href="#bib1200">41</a>They are frequently used in hypertensive or HF patients. Electrolyte imbalance is common in patients receiving diuretics, particularly hypokalaemia, which increases the risk of tachycardia and ventricular fibrillation.<a class="elsevierStyleCrossRef" href="#bib1515">104</a> Hypokalaemia increases perioperative mortality,<a class="elsevierStyleCrossRef" href="#bib1520">105</a> and preoperative potassium and magnesium levels must always be determined.Aldosterone antagonists, spironolactone and eplerenone, block the action of aldosterone receptors by increasing sodium and water excretion in urine and reducing potassium levels. They should only be used in patients with good kidney function and normal serum potassium levels. The beneficial effect of diuretics on cardiac remodelling, myocardial fibrosis and regression of hypertrophy has earned them a place in long-term HF treatment strategies. Several studies have found them to have a beneficial effect on survival.<a class="elsevierStyleCrossRefs" href="#bib1050">11,48,106–108</a>Preoperative up-dosing of diuretics can cause relative hypovolaemia, which is often asymptomatic, and far from being beneficial, can even destabilise the patient. Diuretics should be continued until the day of surgery, and then restarted, intravenously if needed, as soon as possible. Hypovolaemia and electrolyte disturbance are the main problems encountered in these patients.<a class="elsevierStyleCrossRef" href="#bib1530">107</a>4.5.5AspirinAspirin is a common therapy in HF, but few studies on the perioperative use of this drug have been published.<a class="elsevierStyleCrossRefs" href="#bib1545">110,111</a>The effects of aspirin on coagulation have been widely debated. Aspirin should not be suspended to deliver locoregional anaesthesia.<a class="elsevierStyleCrossRef" href="#bib1555">112</a> Perioperative aspirin increases the risk of bleeding by 1.5%, but does not cause any serious complications.<a class="elsevierStyleCrossRef" href="#bib1560">113</a> The risk of serious cardiovascular complications following interruption of aspirin, however, is three times higher.<a class="elsevierStyleCrossRef" href="#bib1565">114</a> Aspirin should not, a priori, be suspended for minor surgery or endoscopy.4.5.6AnticoagulantsComorbidity is extremely common in HF patients, and they are at risk for thromboembolic complications. Anticoagulation with coumarin derivatives should be maintained in all HF and chronic or paroxysmal atrial fibrillation patients. Anticoagulants should be given to patients presenting significant ventricular dilation, ventricular aneurysm, or LVEF less than 20% in sinus rhythm. Anticoagulants are associated with increased bleeding during noncardiac surgery. In some procedures, such as cataract surgery, the benefits of anticoagulation therapy outweigh the risk of haemorrhage, and should be continued.Patients receiving oral anticoagulation with vitamin K antagonists are at greater risk for peri- and postoperative bleeding. Surgery can safely be performed, provided INR is <1.5. In this case, however, due to the risk of thrombosis, bridge therapy with low-molecular-weight heparins should be given in accordance with well-established protocols.<a class="elsevierStyleCrossRef" href="#bib1570">115</a>4.5.7Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs)ACE inhibitors are indicated in any functional class of systolic HF (LVEF<40%), in the absence of contraindications or intolerance. They have been shown to delay evolution of the disease, improve symptoms, and reduce mortality. The secondary effects of ACE inhibitors include kidney failure, hypokalaemia, symptomatic hypotension, unproductive cough in up to 10–15% of patients, and even angiooedema.<a class="elsevierStyleCrossRefs" href="#bib1145">30,38</a>Their endothelial and anti-inflammatory action protects against organ damage, which could be beneficial in the postoperative period.<a class="elsevierStyleCrossRefs" href="#bib1575">116,117</a> Therefore, they should be continued, despite concerns initially raised about their effect on kidney function.<a class="elsevierStyleCrossRef" href="#bib1585">118</a> They do, however, cause severe hypotension during anaesthesia, particularly in patients taking beta-blockers. Hypotension is less severe if ACE inhibitors are interrupted 24h before surgery, although this indication is still under discussion. Hypotension is more severe and difficult to control in patients taking ARBs.<a class="elsevierStyleCrossRef" href="#bib1540">109</a>ARBs are indicated in systolic HF when ACE inhibitors are poorly tolerated, or in patients with persistent symptoms refractory to ACE inhibitors and a beta-blocker. They have been shown to be equally beneficial as ACE inhibitors in reducing the risk of mortality. They should not be given to patients taking combination ACE inhibitor plus aldosterone receptor antagonist.<a class="elsevierStyleCrossRefs" href="#bib1145">30,38,119</a>4.5.8Calcium channel blockersCalcium channel blockers can be used to reduce risk, however, it is important to distinguish between dihydropyridines, which do not directly affects heart rate, and diltiazem or verapamil, which decrease heart rate. Although evidence is scant, an analysis of the literature shows that they reduce ischaemia and supraventricular tachycardia.<a class="elsevierStyleCrossRefs" href="#bib1595">120,121</a>4.5.9Alpha-2 agonistsAlpha-2 agonists can reduce intraoperative catecholamine release. Although there is no conclusive evidence that they reduce mortality or myocardial infarction in HF patients undergoing intermediate or high risk surgery,<a class="elsevierStyleCrossRefs" href="#bib1605">122,123</a> they have been shown to reduce morbidity and mortality in the vascular surgery subgroup. Some more recent studies have reported that perioperative clonidine is effective in reducing mortality.<a class="elsevierStyleCrossRef" href="#bib1615">124</a>4.5.10Pharmacological management of diastolic heart failure<a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a> shows the treatment schedule for diastolic HF.<a class="elsevierStyleCrossRefs" href="#bib1060">13,30,34,46,48</a> As yet, no treatment has been shown conclusively to reduce morbidity and mortality in HF patients with preserved LVEF. Diuretics are used to control sodium and water retention and reduce dyspnoea and oedema, as in HF with depressed LVEF. In patients with AF, it is important to control myocardial ischaemia, hypertension and heart rate. Remember, calcium channel blockers can improve symptoms and exercise capacity in these patients, but they are not recommended in patients with ventricular dysfunction due to their negative inotropic effect. Beta-blockers can also be used to control heart rate in patients in AF and in patients with HF with preserved LVEF.<a class="elsevierStyleCrossRefs" href="#bib1030">7,48,64</a> The same drugs advised against in systolic HF are also discouraged in diastolic HF, with the exception of calcium channel blockers.4.6Preoperative revascularisation as a risk reduction strategy<elsevierMultimedia ident="tb0055"></elsevierMultimedia>Preoperative bypass prevents acute myocardial infarction. However, although it is extremely effective in severe stenosis, it cannot prevent plaque rupture caused by the stress response to surgery.<a class="elsevierStyleCrossRef" href="#bib1205">42</a>Stable patients can safely undergo noncardiac surgery five years after bypass surgery, irrespective of their LVEF.<a class="elsevierStyleCrossRef" href="#bib1620">125</a>In patients with stents, mortality due to acute intraoperative thrombosis of the stent is as high as 20% when surgery is performed a few weeks after implantation and antiplatelet therapy has been suspended. This is why elective surgery should be postponed for at least 6 weeks or up to 3 months, if possible, following implantation of bare metal stents, as shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>.<a class="elsevierStyleCrossRef" href="#bib1625">126</a> After this time, surgery can be performed if aspirin is maintained.<a class="elsevierStyleCrossRef" href="#bib1630">127</a>The situation is very different with drug-eluting stents (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), since aspirin and clopidogrel must be continued for at least 12 months. If, during this interval, the patient requires surgery and antiplatelet treatment is suspended, the risk of complications increases.<a class="elsevierStyleCrossRef" href="#bib1635">128</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Very little information is available on the use of prophylactic revascularisation in patients with stable ischaemic heart disease. The “Coronary Artery Revascularization Prophylaxis (CARP)” study found that revascularisation prior to vascular surgery had no discernible effect. Initially, no differences were observed in long-term mortality at 2.7 years following inclusion in the study.<a class="elsevierStyleCrossRef" href="#bib1640">129</a> However, the inclusion criteria for this study are controversial, and the study population was relatively low-risk.The benefit of revascularisation in patients with stable ischaemic heart disease scheduled for surgery remains unclear, and recommendations are associated with a low level of evidence. Revascularisation is a reasonable strategy, although bypass surgery is needed in significant left main artery disease and triple vessel disease, particular with LVEF involvement. Percutaneous coronary intervention should be performed in symptomatic, stable, single- or double-vessel disease.<a class="elsevierStyleCrossRefs" href="#bib1645">130,131</a>Prophylactic revascularisation in patients with unstable ischaemic heart disease scheduled for noncardiac surgery has not been investigated. Unstable angina and non-ST elevation ACS are high risk situations that require revascularisation.<a class="elsevierStyleCrossRef" href="#bib1655">132</a> In patients with unstable angina scheduled for urgent surgery (cancer surgery, etc.), particular care should be taken to avoid intensive use of anticoagulants and/or antiplatelet therapy due to the increased risk of secondary haemorrhage.In patients with unstable angina scheduled for non-urgent noncardiac surgery, bare metal stents should be implanted to avoid delaying the intervention by more than 3 months.4.7Perioperative arrhythmia in heart failure patients undergoing noncardiac surgery<elsevierMultimedia ident="tb0060"></elsevierMultimedia>Arrhythmias are common in HF patients undergoing general anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib1660">133,134</a> Tachycardia is a serious, complex problem that worsens ischaemia and compromises haemodynamic stability by shortening diastolic filling time and preventing full ventricular filling. Tachycardia in HF patients can have serious consequences,Tachycardia can also significantly compromise the evolution of coronary patients, or patients with either systolic or diastolic HF. Aggressive treatment is needed to address tachycardia, once anaemia, hypovolaemia, pain, and catecholamine overdose have been ruled out. Short-acting beta-blockers such as esmolol are first line therapy in tachycardia, particularly in coronary patients.4.7.1Ventricular arrhythmiaAlthough ventricular premature beats are common, they are not associated with poorer prognosis. Sustained monomorphic ventricular tachycardia with serious haemodynamic compromise must be treated promptly with electric cardioversion.<a class="elsevierStyleCrossRef" href="#bib1245">50</a> Initially, intravenous amiodarone should be given.Patients with sustained polymorphic ventricular tachycardia and haemodynamic deterioration must be treated promptly with electric cardioversion. Beta-blockers are useful in these patients if ischaemia is suspected. Amiodarone is also a reasonable therapeutic option in the absence of long QT syndrome.<a class="elsevierStyleCrossRef" href="#bib1245">50</a>Torsades de Pointes rarely occurs. If it does, it should be treated with magnesium sulphate, and when triggered by sinus bradycardia, pacing and suspension of beta-blockers is recommended. Isoproterenol is recommended in patients with recurrent pause-dependent Torsades de Pointes who do not have congenital long QT syndrome.<a class="elsevierStyleCrossRef" href="#bib1245">50</a>4.7.2Supraventricular arrhythmiaSupraventricular arrhythmias are far more prevalent.<a class="elsevierStyleCrossRefs" href="#bib1245">50,135</a> The main trigger mechanism of these arrhythmias is sympathetic activity.<a class="elsevierStyleCrossRef" href="#bib1665">134</a> Vagal manoeuvres may terminate supraventricular arrhythmias in some cases. These arrhythmias respond well to treatment with adenosine, but when this fails, esmolol or a non-dihydropyridine calcium channel blocker (diltiazem and verapamil) or IV amiodarone should be given.<a class="elsevierStyleCrossRef" href="#bib1075">16</a>AF is undoubtedly the most common form of arrhythmia. Amiodarone or diltiazem are important in chronic or new onset AF with rapid ventricular response. If beta-blockers have been ruled out, and AF is new onset, the treatment of choice should be electric defibrillation.<a class="elsevierStyleCrossRefs" href="#bib1220">45,136</a> Digitalis and similar drugs should only be first-line therapy in patients with chronic HF, since they are not effective in high adrenergic states such as surgery. Beta-blockers have been shown to accelerate the conversion of AF to sinus rhythm after noncardiac surgery.<a class="elsevierStyleCrossRef" href="#bib1680">137</a>4.7.3Implantable devices and surgeryElectrocautery is dangerous in pacemaker-dependent patients, as the electrical stimulus from the device interferes with the pacemaker. The problem can be avoided by placing the ground plate for the electric circuit in such a way that the electrical current travels away from the generator. Keeping the electrocautery device away from the pacemaker, giving only brief bursts and using the lowest possible amplitude may decrease the interference.Some authors recommend setting the pacemaker in asynchronous or non-sensing mode in pacemaker-dependent patients, and reprogramming after surgery.<a class="elsevierStyleCrossRef" href="#bib1685">138</a>Similar interference can also occur with implantable cardioverter defibrillators during surgery. They should be deactivated during the intervention and reactivated in the recovery room prior to transferring the patient to the ward.<a class="elsevierStyleCrossRef" href="#bib1690">139</a>5Intraoperative risk reduction in HF patients scheduled for noncardiac surgery<elsevierMultimedia ident="tb0065"></elsevierMultimedia>This section deals with limiting risks perioperatively and in the immediate preoperative period. The concept of risk reduction<a class="elsevierStyleCrossRef" href="#bib1180">37</a> is based on a broad view of the patient as a whole before, during and after the intervention. When applied to heart surgery, risk reduction could be defined as preservation of intraoperative cardiac function at all times, particularly during surgery, irrespective of the patient's situation, in the knowledge that the task will become more difficult as myocardial function worsens. It is important to bear in mind that the worse the preoperative functional status, the greater the perioperative deterioration.This simple concept reveals the fundamental need to make every effort to optimise patients with compromised heart function, i.e., depressed LVEF; optimisation and cardioprotection are the key words.Clinicians are well aware of the importance of monitoring and anaesthetic technique, despite scarce evidence in the literature, while preconditioning and haemodynamic optimisation are new strategies that can play a fundamental role in reducing risk in HF patients.Goal-directed haemodynamic optimisation therapy (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) is of the utmost importance in HF patients. It is important to stress that optimisation is only possible with good monitoring (<a class="elsevierStyleCrossRef" href="#tbl0050">Table 8</a>).<a class="elsevierStyleCrossRefs" href="#bib1080">17,140</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0050"></elsevierMultimedia>Conditioning can be defined as the process of stimulating biological mechanisms capable of limiting the structural or functional damage caused by an injury. Conditioning can be achieved by drugs or ischaemic manoeuvres. If the drug or manoeuvres are effective before the injury occurs, it is called preconditioning. If it is effective while the injury occurs, it is called conditioning; and if it is effective after the injury occurs, it is called postconditioning. In all three strategies, the mechanism remains the same; only the point at which the drug is administered or the ischaemic manoeuvre performed differs.<a class="elsevierStyleCrossRefs" href="#bib1700">141–148</a>5.1Haemodynamic monitoringBasic monitoring techniques required in all anaesthetic procedures might not be sufficient in more high-risk patients, although there is little evidence to corroborate this.<a class="elsevierStyleCrossRef" href="#bib1740">149</a> Central venous pressure and invasive arterial pressure monitoring, though useful, are insufficient.<a class="elsevierStyleCrossRefs" href="#bib1745">150–152</a> In HF patients, therefore, advanced haemodynamic monitoring is based on parameters that can facilitate perioperative haemodynamic optimisation (<a class="elsevierStyleCrossRef" href="#tbl0050">Table 8</a>). The techniques usually used are central venous oxygen saturation (ScvO2)<a class="elsevierStyleCrossRef" href="#bib1760">153</a> pulmonary artery catheter (Swan Ganz), including continuous thermodilution cardiac output monitoring (CCO) and mixed oxygen saturation (SvO2),<a class="elsevierStyleCrossRefs" href="#bib1765">154–157</a> pulse wave analysis systems, including transpulmonary thermodilution (PiCCO), lithium dilution (LIDCO),<a class="elsevierStyleCrossRefs" href="#bib1785">158,159</a> partial carbon-dioxide (CO2) rebreathing,<a class="elsevierStyleCrossRef" href="#bib1795">160</a> transthoracic electrical bioimpedence<a class="elsevierStyleCrossRefs" href="#bib1800">161–163</a> and ultrasound monitoring techniques, including transesophageal Doppler<a class="elsevierStyleCrossRefs" href="#bib1815">164,165</a> or echocardiography.<a class="elsevierStyleCrossRefs" href="#bib1190">39,166–168</a>Pulmonary artery catheters are not usually indicated due to the characteristics of HF patients. Some studies report no benefits in the use of this technique,<a class="elsevierStyleCrossRefs" href="#bib1840">169,170</a> and no differences in mortality and length of hospital stay, although patients with pulmonary artery catheter were more prone to pulmonary embolism.The choice of monitoring technique depends on a wide range of factors that are outside the scope of this guideline. However, the choice of parameter or parameters measured will be essential to guide therapeutic decisions aimed at minimising the consequences of surgical aggression. In all monitoring techniques, it is important to evaluate any possible complications arising from their use, and the level of evidence assigned to their indication.However, monitoring options are sometimes limited by the resources available. If advanced haemodynamic monitors are not available, a variation of more than 10% in systolic blood pressure between inhalation and exhalation (minimum tidal volume of 8–10ml/kg), shown on an arterial pulse wave, can give an indication of volume response in a hypotensive patient. Variations in plethysmographic waveform can also be used. An increase of more than 5% in arterial pressure 15s after interrupting mechanical ventilation at the end of expiration can predict preload responsiveness.<a class="elsevierStyleCrossRef" href="#bib1755">152</a> If the circumstances call for the use of inotropes, once haemoglobin and afterload have been optimised central venous saturation can be measured from time to time with a central catheter. This will show whether oxygen delivery and consumption are balanced.In conclusion, obtaining useful measurements is the key to monitoring HF patients. The data obtained must be rapidly and reliably updated with the least possible calibration. Monitoring must be adapted to goals, haemodynamic optimisation, the patient's risk, the type of surgery, and the likelihood of complications.5.2Haemodynamic optimisation<elsevierMultimedia ident="tb0070"></elsevierMultimedia>Goal-directed haemodynamic optimisation therapy (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) is a powerful therapeutic strategy that should be used whenever required, although it is usually used in the hours leading up to surgery, during the intervention, and in the first few hours post-surgery.There is ample evidence that high-risk surgical patients treated according to goal-directed haemodynamic optimisation in the perioperative period are at less risk of mortality and morbidity.<a class="elsevierStyleCrossRefs" href="#bib1850">171,172</a> Haemodynamic optimisation is based on oxygen delivery to tissues (DO2). Although monitoring techniques have changed, therapeutic tools remain the same: intravenous solutions (crystalloids, colloids and haemoderivatives), vasoactive drugs (vasopressors, inotropes, vasodilators) and oxygen.The aim of haemodynamic optimisation is to maintain DO2 above critical levels.<a class="elsevierStyleCrossRef" href="#bib1860">173</a> Mixed venous saturation (SvO2) and central venous saturation (ScO2) levels are extremely important.DO2 cannot be improved without first improving cardiac output (CO) and blood oxygen levels (CaO2). CaO2 depends on the haematocrit and SpO2, preload cardiac output, afterload, heart rate, and LV compliance, in the absence of VD.<a class="elsevierStyleCrossRef" href="#bib1860">173</a>Haemodynamic optimisation requires optimisation of myocardial contractility, preload, afterload, heart rhythm and heart rate, particularly if the patient is in AF, correction of anaemia and adequate gas exchange. In terms of haemodynamics, liquids to increase systolic volume (SV) can only be given in patients with adequate heart function. For this reason, concomitant inotropes are essential in patients with LVEF<40% (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The most widely studied parameters have been systolic volume, cardiac index (CI), mixed or central venous saturation (SVO2) and oxygen delivery (DO2). Studies have shown that this strategy improves outcomes.In practical terms, cardiac output must be optimised without causing fluid overload, which can be extremely harmful to these patients. Estimating cardiac preload using dynamic indices can give early indication of the need for inotropes. In unstable or high-risk patients, preoperative haemodynamic optimisation is usually achieved with catecholamines, as shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>. This strategy has been shown to be extremely effective.<a class="elsevierStyleCrossRefs" href="#bib1850">171,174</a>If the myocardium is unresponsive to preload, cardiac function must be increased pharmacologically and the cause of the dysfunction analysed without delay: anaemia, low diastolic pressure, ischaemic event or acute mechanical complication. This means that at times inotropic support can be started, and then withdrawn with haemoglobin delivery, or afterload can be adjusted to ensure filling. Automated intraoperative ST segment monitoring with lead combinations can warn of ischaemic events.<a class="elsevierStyleCrossRef" href="#bib1080">17</a>Despite their effectiveness, catecholamines have some important side effects, mainly increased myocardial oxygen consumption. Some studies have reported that catecholamine and phosphodiesterase inhibitors increase mortality in HF patients,<a class="elsevierStyleCrossRefs" href="#bib1870">175–178</a> although these findings are not echoed by other authors.<a class="elsevierStyleCrossRefs" href="#bib1160">33,47,179–182</a> It is important to note that this increase in mortality is based on data from medical patients, and should never be extrapolated to surgical patients, in whom catecholamines and phosphodiesterase inhibitors are essential. These drugs, however, can in some cases be successfully replaced by levosimendan, with even better results.<a class="elsevierStyleCrossRef" href="#bib1910">183</a>Levosimendan, which increases cardiac contractility and vasodilation, is a promising new drug. Goal-directed therapy (GDT), therefore, should ideally start between 12 and 24h prior to surgery.<a class="elsevierStyleCrossRefs" href="#bib1180">37,82,184–187</a>The technique may cause some organisational disruptions, since it requires patients to be transferred to the intensive care unit for continuous monitoring. There is evidence to suggest that perfusion of 0.05–0.2mc/kg/min levosimendan for a total dose of 12.5mg prior to surgery, without a loading dose, improves postoperative haemodynamic status and cardiorespiratory symptoms in HF patients.<a class="elsevierStyleCrossRefs" href="#bib1030">7,82,184,185,187</a>Studies in ischaemia-reperfusion injury have shown patients with inadequate haemodynamic optimisation and/or organ protection can be at risk for serious organic complications post-surgery.<a class="elsevierStyleCrossRefs" href="#bib1935">188–190</a>5.3Conditioning and its role in risk reductionPreconditioning, the best-known stage of conditioning, can be defined as the biological situation in which cellular protection mechanisms are activated as a result of a brief, controlled ischaemic injury.<a class="elsevierStyleCrossRef" href="#bib1700">141</a> Ischaemic conditioning produces an early and then a delayed mitochondrial protection response, with less cellular apoptosis and less immune cell recruitment in the context of a systemic inflammatory response syndrome. It also activates anti-ischaemia, antiarrhythmic, antistunning, antiplatelet mechanisms, and maintains endothelial function. These mechanisms are not only triggered by controlled ischaemia-reperfusion injury, but also pharmacologically, as shown in <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>.<a class="elsevierStyleCrossRefs" href="#bib1945">190,191</a>5.3.1Remote ischaemic conditioningThe concept of remote ischaemic conditioning was developed after observing the same protective effects in organs distant from the organ receiving the partial ischaemia. Although it is not widely used in clinical practice, it is part of the development of conditioning techniques.Studies in humans are showing the advantages of this technique.<a class="elsevierStyleCrossRefs" href="#bib1945">190–194</a> One such study in a series of paediatric patients treated for congenital heart defects has shown that four, 5-min cycles of lower limb ischaemia reduced postoperative cardiac enzyme levels together with the need for inotropes and time on mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib1955">192</a> Salmenperä, in a randomised clinical trial in 82 patients undergoing elective abdominal aortic aneurysm repair, showed a decrease in postoperative myocardial ischaemia events and kidney injury following intermittent crossclamping of the common iliac artery to induce 10-min ischaemia before aortic crossclamping,<a class="elsevierStyleCrossRef" href="#bib1960">193</a> while a study in 225 patients undergoing percutaneous coronary intervention showed that repeated intermittent inflations of an intracoronary balloon reduced the risk of kidney complications.<a class="elsevierStyleCrossRef" href="#bib1965">194</a> Not all authors, however, find remote ischaemic conditioning to be beneficial in cardiac interventions.<a class="elsevierStyleCrossRef" href="#bib1725">146</a>The biological mechanism of conditioning and preconditioning is extremely complex. Ischaemia shuts off ATP production and triggers the release of adenosine, which in turn activates mitochondrial ATP-sensitive K channels, causing vasodilation and reducing the amount of Ca entering the cell.<a class="elsevierStyleCrossRefs" href="#bib1970">195,196</a>There are a number of molecules capable of producing preconditioning or conditioning. P2Y12 receptor antagonists,<a class="elsevierStyleCrossRef" href="#bib1980">197</a> magnesium, nicorandil and pinacidil all activate mitochondrial ATP-sensitive K channels,<a class="elsevierStyleCrossRefs" href="#bib1985">198,199</a> as do delta and kappa opioid agonists,<a class="elsevierStyleCrossRef" href="#bib1705">142</a> volatile anaesthetics,<a class="elsevierStyleCrossRef" href="#bib1995">200</a> propofol<a class="elsevierStyleCrossRef" href="#bib2000">201</a> and calcium sensitisers, namely, levosimendan.<a class="elsevierStyleCrossRefs" href="#bib1405">82,184,185,202–206</a>The action of propofol is more widely debated. Some studies report its protective effect,<a class="elsevierStyleCrossRef" href="#bib2000">201</a> while others describe it as an inhibitor of ischaemic preconditioning.<a class="elsevierStyleCrossRefs" href="#bib2030">207,208</a>5.3.2Pharmacological conditioningTissue conditioning can also be achieved pharmacologically. In the context of cardiac conditioning, halogenated volatile anaesthetics and levosimendan are of particular interest.<a class="elsevierStyleCrossRefs" href="#bib1700">141,188–191</a> Other anaesthetics, namely opioids and propofol, have also been described as cardiac conditioning agents, but far more evidence has been gathered on the use of halogenated volatile anaesthetics in this context.5.3.2.1Halogenated volatile anaesthetics and conditioningSeveral authors<a class="elsevierStyleCrossRefs" href="#bib1080">17,209</a> recommend the use of volatile anaesthetics in certain specific situations, such as myocardial ischaemia. Volatile anaesthetics (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>) have been shown to be effective as conditioning and cell protection agents.<a class="elsevierStyleCrossRefs" href="#bib1735">148,210–212</a> Nonetheless, some authors report widely differing clinical data that seems to contradict the general view.<a class="elsevierStyleCrossRef" href="#bib2060">213</a> In the study in question, however, the dose of opioids and other drugs administered is not clear. As this was left to the discretion of the anaesthesiologist, it could constitute a bias that could skew the results of the study.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Using sevofluorane in the anaesthesia delivered to a deceased-donor liver transplant recipient reduced the incidence of early allograft dysfunction.<a class="elsevierStyleCrossRef" href="#bib1730">147</a> The findings of a retrospective review of liver surgery in several Spanish hospitals also found benefits in the use of volatile anaesthetics, although due to the heterogeneity of the groups studies, no statistical significance was found.<a class="elsevierStyleCrossRef" href="#bib2065">214</a> In these studies, the use of propofol in the control group did not show the same benefits, showing that it does not have a clinically relevant conditioning effect.In another study, bronchoalveolar lavage samples showed less alveolar inflammation in the single ventilated lung of subjects receiving volatile anaesthetics during thoracic surgery.<a class="elsevierStyleCrossRef" href="#bib2070">215</a>5.3.2.2Levosimendan and conditioningThe conditioning mechanism of levosimendan is due to its interaction with ATP-sensitive K channels, and not its contractile and vasodilating properties. It does, however, improve contractility, and is thus the only dual-action potassium channel opener and calcium sensitiser, making it particularly useful in HF patients, above all those with depressed LVEF.<a class="elsevierStyleCrossRefs" href="#bib1915">184,185,202–204,216,217</a>Levosimendan has been shown to have a preconditioning effect even at very low doses. Tritapepe<a class="elsevierStyleCrossRefs" href="#bib1710">143,144</a> and Zangrillo<a class="elsevierStyleCrossRef" href="#bib2085">218</a> have shown that in heart bypass surgery, administration of a 24μg/kg bolus over 10min reduces postoperative serum troponin levels. Although this system could be considered effective, it evidently does not improve contractility.A new precondition, method consisting in the administration of 0.1μg/kg/min levosimendan over 24h prior to surgery, has been tested in HF patients undergoing hip replacement surgery,<a class="elsevierStyleCrossRef" href="#bib1405">82</a> in patients with low LVEF undergoing abdominal surgery,<a class="elsevierStyleCrossRefs" href="#bib1915">184,185</a> and in high-risk patients with seriously compromised LV undergoing heart surgery.<a class="elsevierStyleCrossRefs" href="#bib2080">217,219</a>Although cohort size was small in these studies, all reported positive haemodynamic outcomes, albeit with insufficient power to evaluate mortality. Nevertheless, Landoni found decreased mortality following administration of levosimendan in patients taking catecholamines<a class="elsevierStyleCrossRef" href="#bib2095">220</a> and also in patients undergoing heart surgery.<a class="elsevierStyleCrossRefs" href="#bib2100">221–224</a>There is no evidence to determine the appropriate time to start administration. In patients with depressed LVEF, we recommend early administration in a closely monitored setting, ideally 8 or 12h prior to surgery, at a dose of 0.1–0.2μg/kg/min.The issue of the ideal window of time for administration in still under debate. A practical approach is to assume that some patients will be sent for surgery with no preparation, while others will have been prepared. It is important, therefore, to consider the many different effects of the drug and its onset of action: dose-dependent early preconditioning, inotropism lasting 4–6h with continuous perfusion, immunomodulation in 1h according to in vitro and in vivo studies in HF patients.Administration must be started as soon as possible, provided the aim is to achieve certain goals. If preoperative perfusion is indicated, early intraoperative administration must not be contraindicated except for intolerance or evident risk. There is not enough evidence to recommend systematic use of levosimendan in heart surgery. Nevertheless, it can be considered in high-risk surgery in patients with ischaemia-reperfusion injury where its positive inotropic effect can help postanaesthesia recovery.5.3.3PostconditioningPostconditioning is similar to preconditioning, although it has been far less studied in clinical practice. The controlled ischaemia, or drug, is initially administered after the injury has occurred (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). In experiments and clinical practice, various drugs have been shown to have postconditioning properties; these include volatile anaesthetics, nitrates, opioids, phosphodiesterase type 5 inhibitors, adenosine, diazoxide, erythropoietin (EPO) and levosimendan.<a class="elsevierStyleCrossRefs" href="#bib1735">148,225,226</a> Postconditioning, however, clearly has less clinical importance nowadays.5.4Risk-reducing anaesthetic techniquesPreoperative monitoring and haemodynamic optimisation must continue in the intra- and postoperative periods. There is no need, therefore, to stress the importance of this.Clinical guidelines on perioperative strategies in heart failure patients undergoing noncardiac surgery include few recommendations on intraoperative anaesthetic management,<a class="elsevierStyleCrossRefs" href="#bib1080">17,227</a> although there is abundant information on ischaemic patients undergoing noncardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib1390">79,228</a>Obviously, locoregional anaesthesia in ophthalmology, spinal anaesthesia or nerve blocks are associated with fewer complications than general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib2140">229</a> The exception to this is carotid surgery, where regional anaesthesia has not been shown to reduce neurological or cardiac complications.<a class="elsevierStyleCrossRef" href="#bib2145">230</a> Studies comparing neuraxial blockade vs. general anaesthesia have not confirmed the hypothesis that locoregional anaesthesia is associated with fewer anaesthesia-related complications.Most anaesthetic techniques reduce sympathetic tone, leading to vasodilation and reduction in tissue perfusion pressure. This, however, will never cause tissue ischaemia. Anaesthetic drugs do not appear to significantly impact the evolution of the patient.<a class="elsevierStyleCrossRefs" href="#bib2150">231,232</a>5.4.1Neuraxial blockadeThere is currently insufficient evidence to indicate the superiority of subarachnoid anaesthesia over general anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib2160">233–237</a> A number of studies have been carried out, with varied findings: some report positive findings in subgroups such as abdominal aortic aneurysm surgery, while in others the results are largely similar.<a class="elsevierStyleCrossRef" href="#bib2185">238</a> Thoracic epidural anaesthesia should be considered for patients with heart failure undergoing high-risk surgery.In a meta-analysis, Rodgers<a class="elsevierStyleCrossRef" href="#bib2190">239</a> showed less mortality with regional vs general anaesthesia, although these findings were not echoed by Rigg<a class="elsevierStyleCrossRef" href="#bib2195">240</a> in an Australian study in 900 patients.The aforementioned meta-analysis<a class="elsevierStyleCrossRef" href="#bib2190">239</a> has since been widely criticised due to the poor quality of 6 of the studies included, which were precisely those with statistically significant differences.<a class="elsevierStyleCrossRef" href="#bib2200">241</a>The choice between general anaesthesia or neuraxial blockade will depend, therefore, on the particular pathophysiology of the heart condition and the goals sought.<a class="elsevierStyleCrossRefs" href="#bib2205">242,243</a> When reaching T4, a reduction in cardiac sympathetic drive will appear, which will subsequently override beta blockade. However, beta receptors are still able to respond to catecholamines.Neuraxial blockade in obese patients with heart failure, for example, can cause hypoventilation. This would aggravate their pathology, irrespective of haemodynamic parameters. Similarly, general anaesthesia for minor surgery in a morbidly obese patient could encourage atelectasis, which would also worsen existing pathology.HF patients, moreover, are often on a regimen of antiplatelets or anticoagulants, or simply antithrombosis prophylaxis. In view of this, a number of precautions should be taken both during administration of the blockade, and during withdrawal of IV lines.5.4.2General anaesthesiaAlthough evidence is scarce, as mentioned above, general anaesthesia has been identified as a risk factor in vascular surgery.<a class="elsevierStyleCrossRef" href="#bib1250">51</a>The cardiovascular effects of general anaesthesia include changes in central venous pressure, arterial pressure and cardiac output, and the appearance of arrhythmias. The mechanisms behind these changes are: decreased systemic vascular resistance, decrease myocardial contractility, decreased systolic volume, and increased myocardial irritability. Induction reduces systemic arterial pressure by 20–30%, intubation increases blood pressure by 20–30mmHg, and drugs such as nitrous oxide can reduce cardiac output by up to 15%.<a class="elsevierStyleCrossRef" href="#bib1240">49</a>Although the findings of studies in volatile anaesthetics have been inconsistent,<a class="elsevierStyleCrossRefs" href="#bib2215">244,245</a> they have been shown to protect cardiac function and reduce myocardial injury.<a class="elsevierStyleCrossRefs" href="#bib2150">231,246,247</a> The protective effect of these anaesthetics appears to be greater when they are used throughout the surgical procedure.<a class="elsevierStyleCrossRef" href="#bib2155">232</a> The cardiac conditioning effects of volatile anaesthetics have been discussed in the section on conditioning.5.5Postoperative risk reduction strategyPostoperative care is an integral part of the perioperative strategy. It is focussed on pain management, maintaining normothermia and nutritional status, and preventing haemodynamic, respiratory and kidney complications or any others that may arise. In this guideline we will mainly focus on complications, since these can aggravate existing HF. Other aspects, such as nutrition, will not be dealt with, as it is widely known that perioperative nutritional management is essential in surgical patients, irrespective of their comorbidity.<a class="elsevierStyleCrossRef" href="#bib2235">248</a> However, analysis of nutritional strategies is not within the scope of this guideline.5.5.1Pain managementAnalgesia is essential in surgical patients.<a class="elsevierStyleCrossRefs" href="#bib2240">249–253</a> Postoperative pain is thought to be inadequately managed<a class="elsevierStyleCrossRefs" href="#bib2250">251,254</a> in up to 10% of patients, and this clearly delays recovery, although the evidence that pain causes organ complications after surgery is less clear.Epidural infusion of local anaesthetics and opioids and/or alpha 2-agonists, IV opioids alone or in combination with non-steroid anti-inflammatory drugs seem to be the most effective.<a class="elsevierStyleCrossRef" href="#bib2240">249</a>Postoperative analgesia should, as far as possible, be delivered intravenously. Epidural analgesia has clear advantages over other options; it reduces postoperative stress, improves respiratory complications and shortens ICU stay.<a class="elsevierStyleCrossRef" href="#bib2270">255</a> The quality of regional analgesics for postoperative pain management is beyond dispute; however, the benefits of invasive analgesic techniques should be weighed against the risk of haematoma in patients on antithrombotic drugs or with coagulation disturbances.Patient-controlled analgesia (PCA) is a valid option, although we consider it to be less effective, and more suitable for patients and situations where regional anaesthesia is not advised.<a class="elsevierStyleCrossRefs" href="#bib2250">251,256</a>Non-steroidal anti-inflammatory drugs and COX-2 inhibitors have the potential for promoting heart and renal failure as well as thromboembolic events and should be avoided in patients with myocardial ischaemia.<a class="elsevierStyleCrossRefs" href="#bib2240">249,251,257,258</a>Use of non-steroidal anti-inflammatory drugs and COX-2 inhibitors for post-operative pain control is not recommended in patients with renal and heart failure, myocardial ischaemia, elderly patients, as well as in patients taking diuretics or haemodynamically unstable. The risk of kidney failure is low, however, if these drugs are avoided in patients with compromised kidney function and poor tissue perfusion.<a class="elsevierStyleCrossRefs" href="#bib2280">257–259</a> The risk of worsening HF appears to be similar in both. We consider it advisable to avoid these drugs in patients with kidney failure, HF or unstable angina5.5.2Hypothermia and hypoxiaHypothermia is a significant postoperative complication in HF patients. It leads to increase oxygen consumption, and consequently demand, and increases the incidence of haemorrhage and surgical site infection.<a class="elsevierStyleCrossRef" href="#bib2295">260</a>All clinicians will be familiar with the dramatic effect of hypoxia on any patient. The most effective treatment for hypoxia is analgesia, physiotherapy, oxygenation, and invasive and non-invasive ventilation.Prophylactic physiotherapy, positive end expiratory pressure or non-invasive positive pressure ventilation have not been shown to improve postoperative pulmonary function. All the foregoing methods are effective in treating postoperative respiratory failure.<a class="elsevierStyleCrossRef" href="#bib2300">261</a> The effectiveness of the administration of high-concentration supplemental oxygen is less clear.<a class="elsevierStyleCrossRefs" href="#bib2305">262,263</a>5.5.3Postoperative haemodynamic complications. Acute HFHaemodynamic problems are among the most common, and possible the most serious, postoperative complications.<a class="elsevierStyleCrossRef" href="#bib2315">264</a> They can be caused by many different factors, ranging from simple vasodilation to cardiogenic shock<elsevierMultimedia ident="tb0075"></elsevierMultimedia>5.5.3.1Postoperative hypotension/hypertensionHypotension is common in patients with low cardiac output, and can usually be corrected with medication to treat low cardiac output. However, there is another relatively common postoperative situation, namely systemic inflammatory response syndrome (SIRS). In cardiovascular terms, SIRS causes increase cardiac output and decreased vascular resistance. Neuraxial blockade techniques will aggravate SIRS; low-dose alpha mimetics (phenylephrine, norepinephrine) can be used to boost arterial pressure and prevent vasodilation from prolonging increased CO.<a class="elsevierStyleCrossRef" href="#bib2320">265</a> The situation can usually be corrected in a few hours, although it is important to bear in mind that SIRS can ultimately lead to multiple organ failure.Postoperative hypertension (HTN) is also a common finding and has many different possible causes. Anaesthetic and analgesic techniques have a major impact on these symptoms. HTN increases myocardial VO2, and thus the risk of ischaemia. Patients with HTN are at risk for developing associated morbidity: increased incidence of stroke; LV failure; increased incidence of arrhythmia; bleeding through vascular sutures, and increased risk of haemorrhage.Analgesics, alpha- and beta-blockers, and nitrates are the drugs most commonly using in the postoperative period.5.5.3.2Postoperative low cardiac output syndromeLow cardiac output is a complex complication, as most cardiac complications ultimately lead to this situation. It is extremely common, with a multifactorial aetiology in which the acute postoperative volaemic changes so often seen in these patients plays a fundamental role. Low cardiac output in the postoperative period, however, can vary greatly in terms of seriousness and prognosis, ranging from a minor complication to full cardiogenic shock. <a class="elsevierStyleCrossRef" href="#tbl0055">Table 9</a> shows the most common causes of this syndrome.<a class="elsevierStyleCrossRef" href="#bib1255">52</a> Low cardiac output can be defined as the situation in which cardiac output is insufficient for metabolic demands. It is difficult to determine the exact threshold for low cardiac output in the immediate postoperative period. This is because sedation and hypothermia greatly diminish overall O2 consumption, and the patient may be receiving all the O2 they need with a relatively low cardiac output. Postoperative low cardiac output is usually defined as a cardiac index of less than 2.2l/min/m2.<elsevierMultimedia ident="tbl0055"></elsevierMultimedia>Postoperative low output is treated in much the same way as any other low output situation: optimise preload, control heart rate, optimise vascular resistance and improve contractility.The usual treatment for low output is to increase preload and administer catecholamines. Levosimendan has been shown to be more effective than dobutamine<a class="elsevierStyleCrossRefs" href="#bib2010">203,266,267</a> and phosphodiesterase inhibitors,<a class="elsevierStyleCrossRef" href="#bib2075">216</a> particularly in patients with depressed LVEF.<a class="elsevierStyleCrossRefs" href="#bib2075">216,266–325</a> The current trend is to administer between 0.1 and 0.2μg/kg/min levosimendan without a loading dose.Vasodilators, such as nitroglycerine (NTG) decrease preload and afterload and increase systolic volume. It should only be used in patients with systolic arterial pressure greater than 110mmHg, as it causes hypothermia, a condition that is associated with increased mortality in HF patients, particularly those with aortic or mitral stenosis.<a class="elsevierStyleCrossRef" href="#bib1225">46</a>5.5.3.3Acute heart failure, left ventricular failure and cardiogenic pulmonary oedemaAcute HF (AHF) describes the rapid onset or worsening of signs and symptoms of HF. AHF is one of the postoperative problems associated with HF patients.<a class="elsevierStyleCrossRef" href="#bib2340">269</a> It is extremely serious, and can be triggered by many different factors, which are summarised in <a class="elsevierStyleCrossRef" href="#tbl0060">Table 10</a>. <a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a> shows the treatment schedule for AHF. <a class="elsevierStyleCrossRef" href="#tbl0065">Table 11</a> shows the therapeutic goals. Nevertheless, we disagree with the indiscriminate use of the term acute HF in surgical patients, because it is not entirely accurate. We prefer, instead, to refer to hypotension, hypertension, low output, cardiogenic shock and arrhythmia.<elsevierMultimedia ident="tbl0060"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0065"></elsevierMultimedia>Pulmonary oedema is the most important clinical manifestation of acute HF. It can be defined as a rapid deterioration of the signs and symptoms of HF in previously diagnosed patients, although it often appears in previously undiagnosed patients.<a class="elsevierStyleCrossRef" href="#bib2345">270</a> Postoperative dyspnoea is not synonymous with either HF or pulmonary oedema, since it can have various different causes (<a class="elsevierStyleCrossRef" href="#tbl0070">Table 12</a>).<elsevierMultimedia ident="tbl0070"></elsevierMultimedia>Myocardial ischaemia must immediately be ruled out in all postoperative patients with pulmonary oedema. Myocardial ischaemia is usually diagnosed on the basis of ECG monitoring, echo studies, serial enzymes and coronary angiography.Intraoperative fluid balance must also be evaluated in these patients.<a class="elsevierStyleCrossRef" href="#bib2350">271</a> Diagnosis and treatment must be practically simultaneous. <a class="elsevierStyleCrossRef" href="#tbl0075">Table 13</a> shows the drugs usually used, apart from mechanical systems, to correct fluid imbalance.<elsevierMultimedia ident="tbl0075"></elsevierMultimedia>LV failure with acute pulmonary oedema is an emergency situation that must be addressed immediately to ensure oxygenation, often with mechanical ventilation, and improving LV function with catecholamines and/or vasodilators (if tolerated). The use of intra-aortic balloon counterpulsation is important in these patients.<a class="elsevierStyleCrossRef" href="#bib2355">272</a> Diuretics can initially improve symptoms by reducing congestion. However, they must be used with caution, since they can often cause relative hypovolaemia, which compromises CO.5.5.3.4Cardiogenic shockCardiogenic shock is an extreme form of acute HF and LV failure. It is characterised by persistent and progressive loss of blood pressure with generalised, severe decrease of tissue perfusion beyond the limits necessary to maintain vital organ function at rest.<a class="elsevierStyleCrossRef" href="#bib1280">57</a> Onset of shock is relatively acute and extremely serious. The clinical criteria for diagnosing cardiogenic shock are shown in <a class="elsevierStyleCrossRef" href="#tbl0080">Table 14</a>. Treatment must be based on the principles shown in <a class="elsevierStyleCrossRef" href="#tbl0085">Table 15</a>. Cardiogenic shock is treated mainly with sympathomimetic drugs, dopamine, dobutamine, adrenaline and norepinephrine. Phosphodiesterase inhibitors have a far more limited effect.<elsevierMultimedia ident="tbl0080"></elsevierMultimedia><elsevierMultimedia ident="tbl0085"></elsevierMultimedia>In situations where mechanical circulatory support, intra-aortic balloon pump or ventricular assist devices are used, levosimendan has been shown to significantly improve haemodynamics,<a class="elsevierStyleCrossRef" href="#bib2360">273</a> although there is insufficient research to give this recommendation a high level of evidence. Recent studies have found that the intra-aortic balloon pump did not reduce mortality in cardiogenic shock following acute myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib2365">274</a>5.5.3.5Myocardial ischaemia and acute myocardial infarctionMyocardial ischaemia is a common problem in noncardiac surgery in patients with ischaemic heart disease. One in every six adult surgical patients is at risk of presenting myocardial ischaemia. Incidence of the disease ranges from 18% to 65%. Studies suggest that between 0.1% and 5.6% of these will develop postoperative myocardial infarction, with a mortality rate ranging from 17% to 37%.<a class="elsevierStyleCrossRef" href="#bib1385">78</a>Postoperative myocardial infarction is diagnosed on the basis of the findings of 12-lead ECG study and CPK-MB and troponin levels. However, non-ischaemia-related ECG changes, such as T-wave abnormalities, are often found post-surgery, which is why these changes alone cannot confirm and/or support a diagnosis of myocardial ischaemia. To diagnose postoperative infarction, ECG findings must show the presence of new Q waves and/or persistent ST-T wave changes. Twelve-lead ECG, moreover, has low sensitive for the diagnosis of postoperative infarction in the presence of conduction disorders (bundle branch block) and pacemakers. In these cases, echocardiography is extremely useful.The main goal should be, as far as possible, percutaneous or surgical revascularization. The recommended therapeutic manoeuvres are shown in <a class="elsevierStyleCrossRef" href="#tbl0090">Table 16</a>. The use of inotropes and ventricular assist devices are shown in <a class="elsevierStyleCrossRef" href="#tbl0095">Table 17</a>.<a class="elsevierStyleCrossRefs" href="#bib1080">17,275</a><elsevierMultimedia ident="tbl0090"></elsevierMultimedia><elsevierMultimedia ident="tbl0095"></elsevierMultimedia>6Specific pathologies in heart failure patients6.1Valve disease<elsevierMultimedia ident="tb0080"></elsevierMultimedia>Valvular heart disease (VHD) is a risk factor in patients undergoing noncardiac surgery.<a class="elsevierStyleCrossRefs" href="#bib1080">17,21</a> Echocardiography should be performed on any prospective noncardiac surgery patient with known or suspected VHD. In patients with VHD or prosthetic valves scheduled for noncardiac surgery, endocarditis prophylaxis should be administered to prevent bacteraemia.<a class="elsevierStyleCrossRefs" href="#bib1105">22,28</a>In patients taking anticoagulants, it is important to remember that those with mitral valve prosthesis and atrial fibrillation are at high risk for thrombosis. Therefore, it is imperative to suspend oral anticoagulants and replace with an appropriate heparin regimen.6.1.1Aortic stenosisAortic stenosis is the most common VHD in Europe. Severe stenosis is defined as a valve area of less than 1cm2 or 0.6cm2/m2. Aortic stenosis is an independent risk factor for increased perioperative morbidity and mortality in noncardiac surgery.<a class="elsevierStyleCrossRef" href="#bib2375">276</a>Neuraxial blockade is usually very poorly tolerated due to ensuing vasodilation, and experts recommend the use of invasive haemodynamic monitoring techniques. In the case of elective surgery in patients with symptoms, valve replacement should be considered before surgery. In oncologic surgery, however, the risk/benefit ratio should be carefully evaluated. In these patients, transcatheter aortic valve implantation can be a valid option, although there is little scientific evidence to support this.<a class="elsevierStyleCrossRefs" href="#bib1100">21,26</a>6.1.2Mitral stenosisMitral stenosis is far less complicated than aortic stenosis. The risk of noncardiac surgery is relatively low in these patients, compared with aortic stenosis.Preoperative surgical correction of mitral stenosis is not required in patients with a valve area greater than 1.5cm2 and systolic pressure of less than 50mmHg. In these patients, control of heart rate is essential to avoid tachycardia, which may cause pulmonary oedema.Spinal anaesthesia is often contraindicated in these patients, due to their need for anticoagulation therapy.<a class="elsevierStyleCrossRefs" href="#bib1100">21,277</a>6.1.3Aortic regurgitation and mitral regurgitationNon-significant aortic regurgitation and mitral regurgitation are independent risk factors for cardiovascular complications in noncardiac surgery. Noncardiac surgery can be performed without additional risk in stable, asymptomatic patients with preserved LV function, even in the presence of severe aortic mitral regurgitation. Complications increase significantly, however, when LVEF is below 30%. In this case, noncardiac surgery should be performed only when strictly necessary.<a class="elsevierStyleCrossRef" href="#bib1100">21</a>6.2HypertensionArterial hypertension is not considered an independent risk factor for cardiovascular complications in noncardiac surgery, although these patients should be screened for organ damage and evidence of associated cardiovascular disease. If found, treatment should be given in accordance with usual guidelines.<a class="elsevierStyleCrossRef" href="#bib1090">19</a>Interruption of background hypertension therapy due to surgery should be kept to a minimum. In patients with SAP<180mmHg and DAP<110mmHg, there is no evidence that suspension or postponement of surgery will reduce the risk of complications. Above these levels, experts agree that surgery should be suspended while antihypertensive treatment is optimised.6.3Patients with right ventricular failure. Right-sided heart failureThe right ventricle (RV) is highly sensitive to changes in loading conditions, above all afterload, and has little inotropic reserve. Because of this, pulmonary arterial hypertension (PH) is the most common cause of RV failure.<a class="elsevierStyleCrossRefs" href="#bib2385">278,279</a> Other causes of RV failure include ischaemia, acute or chronic volume overload and an abrupt increase in afterload. <a class="elsevierStyleCrossRef" href="#tbl0100">Table 18</a> shows the main predisposing factors for right ventricle failure.<a class="elsevierStyleCrossRefs" href="#bib1140">29,280,281</a><elsevierMultimedia ident="tbl0100"></elsevierMultimedia>6.3.1Treatment of right ventricular dysfunctionTreatment of RV dysfunction is focussed on reducing afterload, which will be reviewed in the section on PH, and on preserving or increasing ventricular contractility, provided preload is adequate and coronary perfusion pressure remains stable to prevent systemic arterial hypotension.<a class="elsevierStyleCrossRef" href="#bib1140">29</a>Certain inotropes, such as dobutamine, milrinone and isoproterenol, reduce PVR but also SVR, which is why they are sometimes combined with norepinephrine or phenylephrine. Isoproterenol greatly increases myocardial oxygen uptake and causes tachycardia, which restricts its use. Adrenaline and dopamine have a dose-dependent alpha-adrenergic effect. At high doses, therefore, they increase PVR, and a pulmonary vasodilator may be needed.As mentioned above, the therapeutic goal is to reduce pulmonary vascular resistance, facilitate contractility, and maintain arterial pressure at an appropriate level. <a class="elsevierStyleCrossRef" href="#tbl0105">Table 19</a> shows the drugs most commonly used in these indications.<elsevierMultimedia ident="tbl0105"></elsevierMultimedia>In patients with poor response to these therapies, implantation of an intra-aortic balloon pump should be considered to increase coronary perfusion pressure. Alternatively, an extracorporeal assist device, such as an extracorporeal membrane oxygenation (ECMO) system or ventricular assist device may be considered.<a class="elsevierStyleCrossRef" href="#bib2405">282</a>6.4Pulmonary arterial hypertension<elsevierMultimedia ident="tb0085"></elsevierMultimedia>Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure (PAPm) greater than 25mmHg at rest, or >30mmHg with exercise. It is characterised by a progressive increase in pulmonary arterial pressure (PAP), together with a variable degree of vasoconstriction, pulmonary vascular remodelling and in situ thrombosis.Specific consideration should be given to patients with PH due to the high risk of perioperative morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib2390">279–285</a> The most common morbidities associated with this disease are acute respiratory failure (28%), arrhythmia (12%) and CHF (11%). The most common contributory causes of death in this group are left ventricular failure (50% of patients) and respiratory failure. History of pulmonary embolism, NYHA functional class>II, high- and intermediate-risk surgery, and anaesthesia lasting over 3h, are predictors of early mortality.<a class="elsevierStyleCrossRefs" href="#bib2390">279–285</a>Right atrial pressure higher than left atrial pressure can lead to a right-to-left intracardiac shunting through a patent foramen ovale (in 30% of patients) or an atrial septal defect causing arterial desaturation. This is known as Eisenmenger's syndrome.<a class="elsevierStyleCrossRef" href="#bib2425">286</a> Medical guidelines provide very little information on patients with PH requiring surgery, however, all authors agree on the high risk associated with the intervention.<a class="elsevierStyleCrossRef" href="#bib1140">29</a>6.4.1Risk limitation in patients with pulmonary hypertension. Preoperative assessment and optimisationThe preoperative assessment of patients with PH is the same as the protocol recommended for HF patients, with the exception of arterial blood gas measurement, due to the respiratory impairment commonly found in these patients.<a class="elsevierStyleCrossRefs" href="#bib1140">29,287</a> Echocardiography is the initial or routine study of choice. Right heart catheterisation is standard for the diagnosis of PH. Catheterisation can confirm the initial suspicion, evaluate haemodynamic impairment, help to establish a prognosis, and measure pulmonary vasoreactivity.In these patients, optimisation will depend on the severity of PH and the underlying disease. Surgery can be scheduled provided the patient is stable, with no recent aggravation of the condition. Continuation of all pulmonary vasodilator medication is essential<a class="elsevierStyleCrossRef" href="#bib2415">284</a>: calcium channel blockers, prostanoids, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors. If prolonged interruption s expected (more than 12–24h), oral therapy should be switched to IV. Anticoagulants, diuretics and digitalis will either be continued or suspended, as recommended in other HF patients.If PH diagnosis is made immediately prior to urgent surgery, 50–100mg of oral sildenafil can be given.<a class="elsevierStyleCrossRefs" href="#bib2435">288,289</a>6.4.2Anaesthetic techniques in patients with pulmonary hypertensionOptimised monitoring technique discussed above should be used. In our opinion, pulmonary artery catheterisation, which may be disputed in conventional HF, is indicated in patients with severe PH undergoing intermediate- or high-risk surgery. Intraoperative TEE is recommended, provided it is performed by an expert practitioner. We consider central venous pressure (CVP) to be imperative, albeit in combination with other measurements.Anaesthetic technique should always be based on the following principles: avoid causing hypotension due to excessive vasodilation, maintain preloading, avoid tachycardia and loss of sinus rhythm, avoid anaemia, and avoid acidosis and hypoxia. Nerve and plexus blockade is usually preferred to neuraxial or general anaesthesia, while neuraxial blockade should be chosen over general anaesthesia. When using regional techniques, it is important to consider coagulation status, and bear in mind that systemic epoprostenol has a powerful antiplatelet action. In addition to regional techniques, it is also important to ensure the patient is adequately ventilated and oxygenated to prevent an increase in PVR. Prevention of factors that can increase PVR, such as hypoxaemia, hypercapnia, acidosis, hypothermia and superficial anaesthesia is equally even more important than the anaesthetic technique itself.<a class="elsevierStyleCrossRef" href="#bib2445">290</a>Intradural anaesthesia is not recommended, as it is associated with more abrupt haemodynamic changes; however, at low doses, it can minimise hypotension. Hypotension secondary to nerve blockade is controlled by adjusting volaemia and with alpha adrenergics such as norepinephrine and phenylephrine. Ephedrine and alpha- and beta-adrenergic receptor, are also useful if PH is associated with bradycardia. A combination of general and epidural anaesthesia is a good choice, and also facilitates postoperative analgesic management.<a class="elsevierStyleCrossRefs" href="#bib1140">29,291</a>Epidural anaesthesia should consist of a combination of local anaesthetics and opioids to improve the analgesic effect, and to reduce local anaesthetic dosage and the haemodynamic consequences of nerve blockade. The main risks associated with this technique are venous return impairment, hypotension, and the risk of cardioaccelerator fibre blockade.Thoracic epidural anaesthesia does not affect PVR. Nevertheless, high thoracic epidural should not be used in patients with PH, because blockade of the sympathetic cardiac nerves at T1 and T4 has a negative inotropic and chronotropic effect.<a class="elsevierStyleCrossRefs" href="#bib2205">242,243,279,292,293</a>General anaesthesia is unavoidable in many surgical interventions. In these patients, it gives good haemodynamic and respiratory control.<a class="elsevierStyleCrossRef" href="#bib2465">294</a> Etomidate and propofol are the most commonly used induction drugs, together with benzodiazepines. Anaesthesia should be induced gradually to prevent excessive vasodilation. The intubation site can be desensitised with opioids and lidocaine.No clear advantage has been found between volatile anaesthetics and total intravenous anaesthesia (TIVA). Nitrous oxide is usually contraindicated in adults due to its depressor effect on contractility and pulmonary vasoconstriction.Muscle relaxation should be maintained with non-histamine liberating drugs. Mechanical ventilation should be set to low PEEP levels, between 4 and 8cm H2O, to minimise atelectasis and optimise alveolar recruitment with minimal intrathoracic pressure increase to avoid compromising venous return. Hyperinflation due to high PEEP levels, atelectasis and hypercapnia increase PVR.6.4.3Haemodynamic control. Pulmonary vasodilatorsGlobal, not only right-side, haemodynamic control is fundamental. Many surgical and anaesthesia manoeuvres can lead to a sudden increase in PVR, and subsequently RV failure. Although intravenous vasodilators are effective in reducing PVR, their clinical usefulness is limited by their tendency to cause systemic hypotension. They cause diffuse pulmonary vascular dilation, including unventilated areas, inhibit hypoxic pulmonary vasoconstriction, thus increasing intrapulmonary shunt and restricting oxygenation. Prostaglandins, being powerful platelet aggregation inhibitors, are more effective.<a class="elsevierStyleCrossRef" href="#bib2470">295</a> Epoprostenol has an extremely short half-life (2–3min) and is administered in continuous IV infusion (4–10ng/kg/min). Nitroglycerine (0.1–7μg/kg/min) and sodium nitroprusside (0.1–4μg/kg/min) have traditionally been used.Volatile pulmonary vasodilators do not cause systemic hypotension and improve the ventilation/perfusion ratio and blood oxygen levels by increasing blood circulation in ventilated areas. They are currently the treatment of choice.<a class="elsevierStyleCrossRef" href="#bib2475">296</a>Inhaled nitrous oxide at a concentration of 10–40ppm is very effective. It has a half-life of 2–6s, and can therefore be administered in continuous infusion. It has little bronchodilator activity. It can cause clinical toxicity due to methemoglobinaemia and production of nitrogen dioxide (NO2) and hydroxyl radicals. On a technical level, it is difficult to administer, and requires monitoring of NO, O2 and NO2 levels.<a class="elsevierStyleCrossRef" href="#bib2480">297</a>Volatile prostaglandins are administered via a nebuliser connected to the inspiratory limb of the ventilator. Prostaglandin has a half-life of 3–6min. It is administered by intermittent inhalation at a dose of 14–17μg for 15min, repeated every hour, or as continuous inhalation (50ng/kg/min). Iloprost (10–20μg) is nebulised for 15min. It is a prostacyclin analogue that is stable at room temperature and normal lighting conditions, and has a half-life of 20–30min. Its effect lasts for 60–90min.<a class="elsevierStyleCrossRefs" href="#bib2485">298,299</a>Other inhaled selective pulmonary vasodilators are NTG, sodium nitroprusside and milrinone. Combination NO and inhaled prostacyclin therapy, or the combination of one of these with a phosphodiesterase inhibitor, inhaled milrinone or IV dipyridamole, are also beneficial for maintaining PVR. NO and inhaled prostaglandins must be withdrawn gradually to avoid the possibility of rebound pulmonary hypertension. It must be administered with caution in patients with LV dysfunction, since it can cause acute pulmonary oedema.Patients with right ventricular dysfunction and moderate or severe PH undergoing intermediate- or high-risk surgery will be candidates for preconditiong with levosimendan, which also rapidly reduces PVR, improves RV function, and is effective for several days.<a class="elsevierStyleCrossRefs" href="#bib2405">282,300–303</a>Levosimendan has been clinically proven to be effective in RV infarction,<a class="elsevierStyleCrossRefs" href="#bib1540">109,304–307</a> ARDS<a class="elsevierStyleCrossRef" href="#bib2535">308</a> or following mitral valve surgery.<a class="elsevierStyleCrossRefs" href="#bib2540">309–311</a> Norepinephrine and phenylephrine are most commonly used to maintain vascular resistance. Norepinephrine has the added advantage of have a positive inotropic action. Aside from these effects, levosimendan can impede progression of the vascular remodelling typical of PH, thus reducing vascular wall thickening.<a class="elsevierStyleCrossRef" href="#bib2555">312</a>6.4.4Postoperative care in surgical pulmonary hypertension patientsDecompensation in the postoperative period can be caused by a gradual increase in pulmonary vascular tone, acute pulmonary vasospasm, pulmonary thromboembolism, arrhythmia, elevated sympathetic tone, and volaemic variations. Respiratory failure is the most common postoperative complication.Hypoxaemia, hypercapnia, hypotension, hypovolaemia and pain should be avoided. Pulmonary vasodilation medication started during surgery should be withdrawn gradually, and chronic vasodilation treatment should be restarted as soon as possible.<a class="elsevierStyleCrossRef" href="#bib2455">292</a>6.5Heart failure and sepsisSevere sepsis and septic shock are common in our hospitals. They cause major haemodynamic changes, and can affect contractility to the point that these conditions can be considered a special form of acute HF.<a class="elsevierStyleCrossRef" href="#bib2560">313</a> The definition, aetiological diagnosis and treatment of sepsis are outside the scope of this guideline. In this section, we will deal with sepsis as it relates to acute myocardial insufficiency.In cardiovascular terms, sepsis causes a combination of hypovolaemia, decreased vascular tone, myocardial depression and microcirculatory problems.<a class="elsevierStyleCrossRefs" href="#bib2565">314,315</a> Fluid therapy is still the first line treatment.<a class="elsevierStyleCrossRefs" href="#bib2560">313,316–318</a> In HF patients, however, early use of vasopressors, which are essential to restore haemodynamic stability, is needed to prevent fluid overload. Despite the controversy surrounding its use and potentially damaging effect on arrhythmia, immunomodulation and metabolic rate, norepinephrine continues to be the first choice therapy in sepsis.<a class="elsevierStyleCrossRefs" href="#bib2560">313–315</a>Adrenaline should only be used when an additional drug is needed to maintain perfusion pressure, and vasopressin, which should not be used as first line treatment, can be used in combination with adrenaline to down-dose vasoconstrictors.<a class="elsevierStyleCrossRef" href="#bib2560">313</a> Dopamine may only be used as an alternative therapy in certain patients with bradycardia and at low risk for arrhythmia. Phenylephrine should only be used when norepinephrine causes arrhythmia.Dobutamine to improve contractility must be given in doses of up to 20μg/kg/min when adequate cardiac output has not been achieved.<a class="elsevierStyleCrossRefs" href="#bib2565">314,315,319–322</a>Although vasodilators are, in theory, justified in sepsis,<a class="elsevierStyleCrossRef" href="#bib2610">323</a> their use is not discussed in goal-directed guidelines. IV administration is needed to correct hypovolaemia, increase perfusion pressure and improve contractility.Calcium sensitisers are not included in the latest Surviving Sepsis Campaign guidelines.<a class="elsevierStyleCrossRef" href="#bib2560">313</a> Although their use in sepsis patients has been explored in both clinical and experimental studies,<a class="elsevierStyleCrossRefs" href="#bib2615">324–331</a> evidence is sparse, and they should only be used when needed.6.6Heart failure and renal replacement therapyMost (90%) HF patients are admitted to hospital due to volume overload.<a class="elsevierStyleCrossRef" href="#bib1175">36</a> In HF patients with anasarca, the first priority must be to extract excess fluid. IV loop diuretics significantly increase urine output and natriuresis to alleviate initial symptoms of dyspnoea and oedema, but they become less effective with each new administration. In addition, loop diuretics are not without their side effects, which include neurohormonal alternations and electrolyte imbalance. In these cases, a valid and increasingly popular alternative is renal replacement. Several studies have shown that ultrafiltration is a safe method of reducing volume overload. During extracorporeal ultrafiltration, preload is maintained by drawing interstitial fluid into the intravascular space. Ventricular filling pressures are reduced by reducing the amount of extravascular lung water. The normalisation of pulmonary function improve cardiac function, reduces the cardiac silhouette and optimises the restrictive haemodynamic pattern.<a class="elsevierStyleCrossRef" href="#bib2655">332</a>It is important to consider whether renal replacement techniques affect the action of medication given to treat congestive HF. Some studies have reported variations in plasma antimicrobial levels in dialysed patients and the need to up-dose to ensure effectiveness, but little information is available on the drugs used to treat HF.<a class="elsevierStyleCrossRef" href="#bib2660">333</a>Digoxin is not dialyzable, therefore dosage must be adjusted to a glomerular filtration rate of less than 10ml/min. Amiodarone, however, needs no dosage adjustment during dialysis. The action of 5–25μg/kg/min dopamine and dobutamine is not affected by continuous haemofiltration, and does not need to be adjusted during renal replacement.<a class="elsevierStyleCrossRefs" href="#bib2665">334,335</a>Norepinephrine and adrenaline lose 0.1% of their administered dose during renal replacement. Since this loss is insignificant, dosage adjustment is unnecessary, and this extracorporeal filtration has not been shown to affect the patient's haemodynamic status.<a class="elsevierStyleCrossRefs" href="#bib2665">334,335</a>In the case of Milrinone, half-life is extended during renal replacement, and dosage must be adjusted accordingly.<a class="elsevierStyleCrossRef" href="#bib2675">336</a>The pharmacokinetics of levosimendan in patients with mild to moderate kidney failure is similar to its action in healthy individuals. The effect of haemodialysis on the pharmacokinetics of levosimendan has not been determined, and the action of its active metabolite in kidney failure has not been investigated. Therefore, levosimendan should be used with caution in these patients. Clearance is approximately 3.0ml/min/kg, and it has a half-life of around one hour; 54% of the dose is excreted in urine and 44% in the faeces. Over 95% of the administered dose is excreted in one week. Trace amounts (<0.05%) are excreted unchanged in urine. Circulating OR-1855 and OR-1896 metabolites are slow to form and eliminate. Levosimendan should not be used in severe renal impairment with creatinine clearance <30ml/min.<a class="elsevierStyleCrossRef" href="#bib2500">301</a>6.7Mechanical ventilation in heart failure patientsRespiratory failure due to decompensated CHF is usually treated with diuretics and oxygentherapy. However, surgical patients often need invasive or nonsustained ventilatory support, although current trends prioritise non-invasive ventilation.<a class="elsevierStyleCrossRef" href="#bib2680">337</a>In this context, the need for mechanical ventilation can vary greatly. For example, in patients with acute coronary syndrome undergoing percutaneous coronary intervention, mechanical ventilation is usually used when complications occur. These, in order of importance, are cardiac arrest, acute pulmonary oedema and cardiogenic shock. The mortality rate in these patients is as high as 30%.<a class="elsevierStyleCrossRef" href="#bib2685">338</a> Mechanical ventilation is among the interventions associated with the highest mortality rates in coronary care units, relative to the patient's underlying pathology,<a class="elsevierStyleCrossRef" href="#bib2690">339</a> although mortality associated with mechanical ventilation in intensive care units has decreased in recent years.<a class="elsevierStyleCrossRef" href="#bib2695">340</a>Patients with deteriorated heart failure usually present hypoxia, increased work of breathing, increased oxygen uptake, and decreased cardiac output. Mechanical ventilation facilitates the work of breathing and of the heart, and improves oxygen uptake.6.7.1Effect of mechanical ventilation on haemodynamics in patients with acute pulmonary oedemaPatients with deteriorated heart failure usually present hypoxia, increased work of breathing, increased oxygen uptake, and decreased cardiac output. Mechanical ventilation can have a positive effect on all these symptoms.<a class="elsevierStyleCrossRefs" href="#bib2700">341–343</a>In conclusion, in patients with a health heart, mechanical ventilation can reduce venous return, and consequently, cardiac output. In patients with significant heart failure and increased preload, increasing intrathoracic pressure can improve ventricular function, and consequently, cardiac output.6.7.2The role of PEEPOn the subject of mechanical ventilation, the increase in intrathoracic pressure induced by PEEP can improve heart function in HF patients, albeit at the expense of reducing pre- and afterload. PEEP can also help improve pulmonary gas exchange, albeit at the expense of the resulting alveolar recruitment and subsequently of the gas exchange surface; this leads to a reduction in intrapulmonary shunt.<a class="elsevierStyleCrossRefs" href="#bib2700">341,344</a>6.7.3Weaning from mechanical ventilationThe change from positive to negative intrathoracic pressure has a number of pathophysiological consequences. It poses no problem in most patients, because the cause of the pulmonary oedema has been resolved (arrhythmia, ischaemia, hypertensive crisis, etc.), and appropriate treatment can also resolve low cardiac output.In some patients, however, weaning from mechanical ventilation is particularly difficult:<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0350">a.Patients with significantly depressed heart function: Weaning from mechanical ventilation associated with a heart problem is often unsuccessful in patients with depressed heart function. These patients are unable to respond to the haemodynamic changes of spontaneous breathing, due to increased venous return and increased work of breathing. In this situation, weaning must be done gradually while continuing cardiovascular support medication. Diuretics, inotropes and vasodilators are indicated during weaning due to excessive preload, increased afterload or associated myocardial ischaemia.<a class="elsevierStyleCrossRef" href="#bib2720">345</a> In addition, ventilatory modes (with PEEP) that facilitate a gradual return to spontaneous breathing should be used. Non-invasive ventilation is important in this clinical situation. Studies are currently exploring predictive factors for weaning failure, in which BNP could be predictor for failure following cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib2725">346</a></li><li class="elsevierStyleListItem" id="lsti0355">b.Patients with severe left ventricular dysfunction and comorbid COPD: In this situation, weaning from mechanical ventilation can cause a new pulmonary oedema that would prevent withdrawal of ventilatory support. There are a number of factors leading to onset of cardiogenic pulmonary oedema<a class="elsevierStyleCrossRef" href="#bib2730">347</a>:</li></ul><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0360">b.1.Change from positive to negative intrathoracic pressure: This, as mentioned above, increases venous return. In COPD patients, however, this can have major implications since these patients already have a certain amount of autoPEEP (auto-positive end expiratory pressure), and therefore need much greater negative pressure to achieve adequate tidal volume. The greater the negative intrathoracic pressure, the greater the venous return, and subsequently, preload. Negative pressure, meanwhile, is associated with an increase in afterload, which is in turn associated with an increase in left ventricular transmural pressure.</li><li class="elsevierStyleListItem" id="lsti0365">b.2.Activation of the sympathetic nervous system: This increases venous tone and subsequently the volume of blood returning to the heart, in other words, preload. It also increases systolic arterial pressure at the expense of an increase in arteriolar resistance, which evidently increases afterload.</li></ul><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0370">Both these factors contribute to the failing heart receiving a significant volume of blood which it cannot fully eject, thus increasing the risk of a new episode of acute pulmonary oedema.</li></ul><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0375">b.3.Ventricular interdependence: Right ventricular dilation due to increased venous return and increased pulmonary vascular resistance causes the intraventricular septum to shift to the left, thus increasing left ventricular end diastolic pressure, in other words, it increases afterload and reduces left ventricular end diastolic volume. This in turn reduces cardiac output.<a class="elsevierStyleCrossRef" href="#bib2735">348</a></li><li class="elsevierStyleListItem" id="lsti0380">b.4.Increased pulmonary volume: Can compress left-side cavities due to dynamic hyperinflation caused by airway obstruction in COPD patients.</li><li class="elsevierStyleListItem" id="lsti0385">b.5.Risk of myocardial ischaemia: Associated with changes in the ventilation/perfusion ratio with associated hypoxaemia,<a class="elsevierStyleCrossRef" href="#bib2740">349</a> sympathetic activation caused by weaning, and the increased systolic effort of the left ventricle to meet the demand of increased O2 consumption.</li></ul>In consideration of all the above, it is important to focus treatment on reducing venous return, and furosemide has been shown to prevent pulmonary oedema in most patients,<a class="elsevierStyleCrossRef" href="#bib2730">347</a> improve cardiac contractility and reduce afterload, thus enabling the failing heart to handle the overload caused by weaning in these special situations.6.7.4Non-invasive ventilation in CHF patientsNon-invasive ventilation (NIV) avoids the drawbacks of endotrachael intubation and also improves both oxygenation and the associated metabolic changes.There is ample evidence that NIV increases PO2 compared with patients ventilated through nasal prongs. It also reduces the need for endotrachael intubation in this patient group.<a class="elsevierStyleCrossRef" href="#bib2745">350</a> In addition to increased PO2 and improved metabolism, some studies have shown a decreased mortality in NIV patients.<a class="elsevierStyleCrossRefs" href="#bib2750">351,352</a> In a more recent study, however, Gray et al. found no relationship with mortality, and recommended that CPAP or NIV be considered as adjuvant therapy in patients with acute severe cardiogenic pulmonary oedema in the presence of severe breathing difficulty or lack of progress with drug therapy.<a class="elsevierStyleCrossRefs" href="#bib2760">353–355</a>NIV reduces the work of breathing, at the expense of breathing rate and respiratory muscle effort,<a class="elsevierStyleCrossRef" href="#bib2775">356</a> and neither CPAP nor Bi Pap are associated with an increase in cardiac ischaemic events.<a class="elsevierStyleCrossRef" href="#bib2780">357</a>7Conclusions. Main strengths and weakness of the evidenceHF should not be a contraindication for noncardiac surgical interventions that would reasonably increase life expectancy or improve quality of life; however, it is a predictor of poor prognosis in this patient group.There is Strong evidence to recommend that patients with systolic heart failure scheduled for intermediate- to high-risk surgery are treated in hospitals with ample experience in this field, with the capacity to undertake an appropriate preoperative evaluation, and with an intensive care unit equipped for the postoperative care of these patients.There is Strong evidence that systolic HF has a poorer prognosis than diastolic HF in intermediate- to high-risk surgery.There is Strong evidence that the risk of HF patients depends on the condition of their heart and the type of surgery scheduled.There is strong evidence that elective surgery should always be performed in stable patients that are responding well to treatment.There is evidence that the patient's background medication should be continued until the day of surgery, and restarted as soon as possible.Although some studies have recently rekindled the controversy surrounding continuation of beta-blockers in surgical patients, we consider that there is no strong evidence to recommend their withdrawal in these patients.There is no strong evidence that epidural/spinal anaesthesia is better than general anaesthesia.There is reasonable evidence that, spinal anaesthesia can cause severe, difficult-to-reverse haemodynamic deterioration in severe aortic stenosis. Although there are no studies to confirm that this technique should be contraindicated, we believe it should be performed with the utmost caution.There is strong evidence that volatile anaesthetics, mainly sevofluorane, have a clear cardioprotective action. However, there is no solid evidence that they reduce mortality in these patients.There is strong evidence that levosimendan has a clear preconditioning action, and subsequently, a cardioprotective action. However, few studies have been conducted in this patient group.There is evidence that adequate postoperative analgesia reduces morbidity in this patient group, but there is no strong evidence of its impact on mortality.8Methodology for formulating recommendationsWherever a high Level of Evidence with a strong Grade of Recommendation (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 1</a>) was found in the literature, the authors and reviewers considered the evidence to be strong enough to make a recommendation.Wherever insufficient evidence was found<a class="elsevierStyleCrossRefs" href="#bib2785">358–362</a>, we turned to scientific data and expert opinion, using the modified Delphi method.<a class="elsevierStyleCrossRefs" href="#bib2810">363,364</a>The Delphi method assumes that there are several fields of health science areas where scientific information does not provide sufficiently strong evidence on which to base decisions. These knowledge gaps, therefore, must be filled from other sources of knowledge that stem more from practical experience, and for this purpose the opinion of a group of experts is evaluated. The evaluation process must be systematic and able to withstand scientific assessment.9Factors facilitating and limiting implementation of these guidelines9.1Facilitating factors<ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0390">•HF patients are clearly identified in practically all hospitals.</li><li class="elsevierStyleListItem" id="lsti0395">•HF patients are usually receiving excellent treatment.</li><li class="elsevierStyleListItem" id="lsti0400">•Some hospital are equipped with Cardiac Care Units, where noncardiac surgery in these patients is a common occurrence, and the attending physicians are highly experienced.</li><li class="elsevierStyleListItem" id="lsti0405">•Protocolised preoperative evaluation in these patients is simple and does not place an extra burden on hospital resources.</li><li class="elsevierStyleListItem" id="lsti0410">•No additional budget is needed to follow these guidelines.</li></ul>9.2Limiting factors<ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0415">•Medical staff often underestimates the seriousness of diastolic HF.</li><li class="elsevierStyleListItem" id="lsti0420">•HF is often confused with ischaemic heart disease.</li><li class="elsevierStyleListItem" id="lsti0425">•There is ample information in the literature and evidence on noncardiac surgery in patients with ischaemic heart disease, but far less on noncardiac surgery in HF patients.</li><li class="elsevierStyleListItem" id="lsti0430">•Systolic HF patients cannot always be transferred to hospitals with experience in this disease; therefore, surgery is sometimes performed in less experienced hospitals, where protocolisation is limited and outcomes are poorer.</li><li class="elsevierStyleListItem" id="lsti0435">•Preoperative preconditioning with levosimendan requires patients to be admitted some hours before their surgery so that the treatment can be performed in a unit with monitoring equipment. This could have an impact on bed management in these units.</li></ul>10Economic impact of this CPGImplementation of most of these guidelines does not, a priori, entail addition cost.The only costly recommendation is the use of preconditioning with levosimendan. This, as mentioned above, calls for early admission to monitoring unit, to which must be added the cost of the drug.No studies have as yet analysed the cost/benefit ratio of levosimendan in this indication, although similar studies have been carried out in non-surgical patients.11Updating these guidelinesMedical information is known to grow exponentially. In the 2013 PubMed database alone there are 3529 studies with the term “heart failure” in the title, and a further 358 with the term “cardiac failure”.Evidence considered Strong today can tomorrow be modified on the basis of new findings. However, large organisations cannot publish new guidelines each year, or even every two years. Ideally, guidelines should be reviewed every 4–5 years. Considering that a guideline of these characteristics takes over 12 months to draft, every 3 or 4 years the task force, sponsored by SEDAR, will be reconvened to review these recommendations on the basis of this CPG.Ideally, if any documents that would have a substantial impact on the prognosis of this patient group should emerge at any time before each scheduled review, the SEDAR and the task force will make them known to all association members.SponsorThis CPG has been sponsored by donation from “Orion Pharma” to the Spanish Society of Anaesthesiology, Critical Care and Pain Management (SEDAR) to facilitate publication of this CPG.The sponsor did not select the editors and reviewers involved in drafting this guideline. Editors and reviewers were selected by the coordinating body. The sponsor did not provide the task force with any kind of documentation or studies. The sponsor did not take part in task force meetings.Conflict of interestsAll members of the Working Group and those who participated in the external review.<ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0440">Alvarez Julián: Received fees from Abbott and Orion Pharma for speaking at conferences. Received Clinical and Experimental Research grants from Grunenthal and Orion Pharma.</li><li class="elsevierStyleListItem" id="lsti0445">Baluja Aurora: None</li><li class="elsevierStyleListItem" id="lsti0450">Calvo Vecino José María: None</li><li class="elsevierStyleListItem" id="lsti0455">Cabadas Rafael: None</li><li class="elsevierStyleListItem" id="lsti0460">Cariñena Agustín: None</li><li class="elsevierStyleListItem" id="lsti0465">García Rafael: None</li><li class="elsevierStyleListItem" id="lsti0470">Gilsanz Fernando: None</li><li class="elsevierStyleListItem" id="lsti0475">González-Juanatey Jose Ramón: None</li><li class="elsevierStyleListItem" id="lsti0480">Gonzalez Ana: Received fees from Orion Pharma. Participated in training programmes organised by Orion Pharma.</li><li class="elsevierStyleListItem" id="lsti0485">Martín Trapero Carlos: None</li><li class="elsevierStyleListItem" id="lsti0490">Muñoz Aguilera Roberto: None</li><li class="elsevierStyleListItem" id="lsti0495">Muñoz Pedro: None</li><li class="elsevierStyleListItem" id="lsti0500">Ortega Urbaneja Montserrat: None</li><li class="elsevierStyleListItem" id="lsti0505">Solera Jorge: None</li><li class="elsevierStyleListItem" id="lsti0510">Veiras Sonia: None</li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Presentation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Introduction" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Scope and objectives" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Target population" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical areas included in the guideline" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Target healthcare area" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Target users" ] ] ] 3 => array:3 [ "identificador" => "sec0045" "titulo" => "Methodology" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Creation of the task force" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Formulation of clinical questions" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Literature search" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Study selection and evaluation of the quality of the evidence" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Formulation of recommendations" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "External review" ] 6 => array:2 [ "identificador" => "sec0080" "titulo" => "Updates" ] ] ] 4 => array:3 [ "identificador" => "sec0085" "titulo" => "Heart failure" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Overview of the importance of systolic and diastolic heart failure in surgical patients" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Diagnosis of heart failure patients" ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Heart failure management" ] 3 => array:3 [ "identificador" => "sec0105" "titulo" => "Risk evaluation in heart disease patients undergoing noncardiac surgery" "secciones" => array:2 [ 0 => array:2 [ …2] 1 => array:2 [ …2] ] ] 4 => array:3 [ "identificador" => "sec0120" "titulo" => "Risk limitation through chronic pharmacologic therapy for heart failure" "secciones" => array:10 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] 3 => array:2 [ …2] 4 => array:2 [ …2] 5 => array:2 [ …2] 6 => array:2 [ …2] 7 => array:2 [ …2] 8 => array:2 [ …2] 9 => array:2 [ …2] ] ] 5 => array:2 [ "identificador" => "sec0175" "titulo" => "Preoperative revascularisation as a risk reduction strategy" ] 6 => array:3 [ "identificador" => "sec0180" "titulo" => "Perioperative arrhythmia in heart failure patients undergoing noncardiac surgery" "secciones" => array:3 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] ] ] ] ] 5 => array:3 [ "identificador" => "sec0200" "titulo" => "Intraoperative risk reduction in HF patients scheduled for noncardiac surgery" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0205" "titulo" => "Haemodynamic monitoring" ] 1 => array:2 [ "identificador" => "sec0210" "titulo" => "Haemodynamic optimisation" ] 2 => array:3 [ "identificador" => "sec0215" "titulo" => "Conditioning and its role in risk reduction" "secciones" => array:3 [ 0 => array:2 [ …2] 1 => array:3 [ …3] 2 => array:2 [ …2] ] ] 3 => array:3 [ "identificador" => "sec0245" "titulo" => "Risk-reducing anaesthetic techniques" "secciones" => array:2 [ 0 => array:2 [ …2] 1 => array:2 [ …2] ] ] 4 => array:3 [ "identificador" => "sec0260" "titulo" => "Postoperative risk reduction strategy" "secciones" => array:3 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:3 [ …3] ] ] ] ] 6 => array:3 [ "identificador" => "sec0305" "titulo" => "Specific pathologies in heart failure patients" "secciones" => array:7 [ 0 => array:3 [ "identificador" => "sec0310" "titulo" => "Valve disease" "secciones" => array:3 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] ] ] 1 => array:2 [ "identificador" => "sec0330" "titulo" => "Hypertension" ] 2 => array:3 [ "identificador" => "sec0335" "titulo" => "Patients with right ventricular failure. Right-sided heart failure" "secciones" => array:1 [ 0 => array:2 [ …2] ] ] 3 => array:3 [ "identificador" => "sec0345" "titulo" => "Pulmonary arterial hypertension" "secciones" => array:4 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] 3 => array:2 [ …2] ] ] 4 => array:2 [ "identificador" => "sec0370" "titulo" => "Heart failure and sepsis" ] 5 => array:2 [ "identificador" => "sec0375" "titulo" => "Heart failure and renal replacement therapy" ] 6 => array:3 [ "identificador" => "sec0380" "titulo" => "Mechanical ventilation in heart failure patients" "secciones" => array:4 [ 0 => array:2 [ …2] 1 => array:2 [ …2] 2 => array:2 [ …2] 3 => array:2 [ …2] ] ] ] ] 7 => array:2 [ "identificador" => "sec0405" "titulo" => "Conclusions. Main strengths and weakness of the evidence" ] 8 => array:2 [ "identificador" => "sec0410" "titulo" => "Methodology for formulating recommendations" ] 9 => array:3 [ "identificador" => "sec0415" "titulo" => "Factors facilitating and limiting implementation of these guidelines" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0420" "titulo" => "Facilitating factors" ] 1 => array:2 [ "identificador" => "sec0425" "titulo" => "Limiting factors" ] ] ] 10 => array:2 [ "identificador" => "sec0430" "titulo" => "Economic impact of this CPG" ] 11 => array:2 [ "identificador" => "sec0435" "titulo" => "Updating these guidelines" ] 12 => array:2 [ "identificador" => "sec0440" "titulo" => "Sponsor" ] 13 => array:2 [ "identificador" => "sec0445" "titulo" => "Conflict of interests" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-30" "fechaAceptado" => "2015-05-04" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Clinical Practice GuidelinePromoted by: SEDARSpanish Society of Anesthesiology, Critical Care and Pain Therapy." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "etiqueta" => "Annex 1" "titulo" => "Literature search" "identificador" => "sec0455" "apendiceSeccion" => array:2 [ 0 => array:3 [ "apendice" => "((((((“perioperative care”[MeSH Terms] AND “Heart failure treatment”[All Fields]) OR (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) OR “Heart failure treatment”[All Fields]) OR ((“heart failure”[MeSH Terms] OR (“heart”[All Fields] AND “failure”[All Fields]) OR “heart failure”[All Fields]) AND (“anaesthesia”[All Fields] OR “anesthesia”[MeSH Terms] OR “anesthesia”[All Fields]))) OR “Heart failure treatment”[All Fields]) OR ((“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh]) AND “anesthesia”[All Fields])) OR (“Intraoperative Complications”[Mesh] AND (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) ((((((“perioperative care”[MeSH Terms] AND “Heart failure treatment”[All Fields]) OR (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) OR “Heart failure treatment”[All Fields]) OR ((“heart failure”[MeSH Terms] OR (“heart”[All Fields] AND “failure”[All Fields]) OR “heart failure”[All Fields]) AND (“anaesthesia”[All Fields] OR “anesthesia”[MeSH Terms] OR “anesthesia”[All Fields]))) OR “Heart failure treatment”[All Fields]) OR ((“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh]) AND “anesthesia”[All Fields])) OR (“Intraoperative Complications”[Mesh] AND (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) AND (“humans”[MeSH Terms] AND (English[lang] OR Spanish[lang]) AND “adult”[MeSH Terms]) ((((((“perioperative care”[MeSH Terms] AND “Heart failure treatment”[All Fields]) OR (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) OR “Heart failure treatment”[All Fields]) OR ((“heart failure”[MeSH Terms] OR (“heart”[All Fields] AND “failure”[All Fields]) OR “heart failure”[All Fields]) AND (“anaesthesia”[All Fields] OR “anesthesia”[MeSH Terms] OR “anesthesia”[All Fields]))) OR “Heart failure treatment”[All Fields]) OR ((“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh]) AND “anesthesia”[All Fields])) OR (“Intraoperative Complications”[Mesh] AND (“Heart Diseases”[Mesh] AND “Heart Valve Diseases”[Mesh] AND “Hypertension, Pulmonary”[Mesh])) AND ((Clinical Trial [ptyp] OR Review[ptyp] OR Meta-Analysis[ptyp] OR systematic[sb]) AND “humans”[MeSH Terms] AND (English[lang] OR Spanish[lang]) AND “adult”[MeSH Terms]) <elsevierMultimedia class="elsevierStyleLink" ident="fx1"></elsevierMultimedia>" "titulo" => "**Refined search" "identificador" => "sec0460" ] 1 => array:3 [ "apendice" => "“perioperative heart failure”[All Fields] OR “heart failure” AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “treatment”[All Fields] OR “therapeutics”[MeSH Terms]) OR ((“heart failure”[MeSH Terms] OR (“heart”[All Fields] AND “failure”[All Fields]) OR “heart failure”[All Fields]) AND (“haemodynamic”[All Fields] OR “hemodynamics”[MeSH Terms] OR “hemodynamics”[All Fields] OR “hemodynamic”[All Fields])) OR “Heart Failure”[Majr] OR ((“Heart failure”[All Fields] AND “Anesthesia, General”[MAJR]) OR “Intraoperative Care”[MeSH Terms]) OR “Preoperative Care”[MAJR] AND ((Meta-Analysis[ptyp] OR Review[ptyp] OR Clinical Trial[ptyp] OR systematic[sb]) AND “last 5 years”[PDat] AND Humans[Mesh] AND (English[lang] OR Spanish[lang]) AND adult[MeSH]" "titulo" => "*Extended search" "identificador" => "sec0465" ] ] ] 1 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0475" ] ] ] ] "multimedia" => array:59 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1607 "Ancho" => 3254 "Tamanyo" => 282437 ] ] "descripcion" => array:1 [ "en" => "Risk reduction strategy that we use in these recommendations." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1625 "Ancho" => 2338 "Tamanyo" => 247395 ] ] "descripcion" => array:1 [ "en" => "Diagnostic algorithm heart failure." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1102 "Ancho" => 2311 "Tamanyo" => 309810 ] ] "descripcion" => array:1 [ "en" => "Global risk of cardiac patients undergoing noncardiac surgery (Taken from 39, with changes by Lopez Sendon JL and authors)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1331 "Ancho" => 2338 "Tamanyo" => 270910 ] ] "descripcion" => array:1 [ "en" => "Noncardiac surgery in patients with coronary stent." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1795 "Ancho" => 2517 "Tamanyo" => 261108 ] ] "descripcion" => array:1 [ "en" => "Example of hemodynamic optimization (Cl=cardiac index; SVV=stroke volume vaiation; SVI=stroke volume index)." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1563 "Ancho" => 3279 "Tamanyo" => 276275 ] ] "descripcion" => array:1 [ "en" => "Mechanism of preaconditioning (LVEF=left ventricular ejection fraction)." ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "From de McMurray JJ 2012, with modifications." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1259 "Ancho" => 2202 "Tamanyo" => 242354 ] ] "descripcion" => array:1 [ "en" => "Treatment of postoperative acute heart failure." ] ] 7 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Implications of strength of recommendation in the GRADE system</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Management/planners \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Implications of a Strong recommendation</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">The great majority of individual would agree with the recommended strategy, and only a small percentage would disagree. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most patients should receive the recommended intervention. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The recommendation can be adopted as a healthcare policy in most circumstances. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Implications of a weak recommendation</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Most individuals would agree with the recommended strategy, but many will disagree. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Different options would be appropriate for different patients. The doctor must help each patient reach the decision that most reflects their values and preferences. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Serious discussions with stakeholders are needed. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944422.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Evidence rating and grades of recommendation." ] ] 8 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Typical symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">More specific symptoms \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elevated jugular venous pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Orthopnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hepatojugular reflux \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Paroxysmal nocturnal dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Third heart sound (atrial gallop) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reduced exercise tolerance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heart murmur \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Less typical symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Less specific symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wheezing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral oedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nocturnal cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary rales \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weight gain (>2kg/week) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diminished vesicular murmur \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weight loss (advanced disease) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tachycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Loss of appetite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Irregular pulse \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PalpitationsSyncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tachypnea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hepatomegaly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ascites \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944416.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Symptomatology of heart failure." ] ] 9 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ACC/AHA</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stage A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">At high risk for HF but without structural heart disease or symptoms of HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Class 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No limitation of physical activity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stage B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Structural heart disease but without signs or symptoms of HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Class II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Slight limitation of physical activity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stage C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Structural heart disease with prior or current symptoms of HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Class III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Marked limitation of physical activity; any activity causes symptoms of HF \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stage D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advanced structural heart disease and marked symptoms of heart failure at rest refractory to the best medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Class IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Symptoms of HF at rest \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944443.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Functional classification according to the American College of Cardiology/American heart Association (ACC/AHA) and of the New York Heart Association (NYHA) based on severity of symptoms and exercise." ] ] 10 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">According to NYHA functional class</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA I \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA III-IV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Refractory HF \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Terminal HF \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diuretics +− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diuretics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SpironolactoneEplerenone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain medication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Digoxin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Digoxin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ACE inhibitors/ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACE inhibitors/ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACE inhibitors and/or ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">B-blocker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B-blocker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">B-blocker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mechanical devicesHeart transplantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative care \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944433.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Management of systolic heart failure</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug/dose \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum dose \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diuretics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NYHA II with signs or symptoms of congestion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chlorthalidone 50–100mg/24–48hFurosemide 20–40mg/dayTorasemide 10–20mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100mg/day240mg/day40mg/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aldosterone receptor antagonists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NYHA III-IV; evaluate for class II with FE=35%Post-IAM HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spironolactone 12.5mg/dayEplerenone 25mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25mg/day50mg/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ACE inhibitors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All patients unless contraindicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Enalapril 2.5mg/dayCaptopril 6.25–12.5mg/8–12hFosinopril 10mg/24hLisinopril 2.5mg/24hPerindopril 2mg/dayQuinapril 5mg/24hRamipril 1.25–2.5mg/12h1.25mg/24h (severe HF)Trandolipril 0.5mg/24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20mg/day50mg/8h40mg/day40mg/day4mg/day20mg/12h10mg/day5mg/day4mg/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients intolerant to ACE inhibitorsAssociated with ACE inhibitors in patients with refractory symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Candesartan 4–8mg/dayValsartan 40mg/12hLosartan 12.5mg/24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32mg/day320mg/day50–100mg/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hydralazine/isosorbide dinitrate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients intolerant to ACE inhibitors or ARBsPatients with symptoms despite ACE inhibitors, ARBs, betablockers and aldosterone antagonists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hydralazine 25mg/6hIsosorbide dinitrate 40–60mg/12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75mg/6h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">B-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All stable patients unless contraindicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carvedilol 3.125mg/12hBisoprolol 1.25mg/24hNebivolol 1.25mg/24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–50mg/12h10mg/24h10mg/24h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Digoxin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NYHA class III–IV and maintain if worsens to IIAtrial fibrillationEnlarged ventricle and third heart sound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Digoxin 0.1250.25mg/dayAdjust according to kidney function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944424.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pharmacological therapy indicated in the treatment of heart failure." ] ] 11 => array:7 [ "identificador" => "tbl0035" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Low-risk. Risk of cardiac complications < 1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dental surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eye surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Breast surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Minor orthopaedic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Minor genitourinary surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reconstructive surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Superficial surgical procedures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Day surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Endoscopy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">X-ray studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intermediate-risk. Risk of cardiac complications 1-5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abdominal surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Thoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Carotid artery surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Head and neck surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prostate surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Endovascular embolization \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Peripheral artery angioplasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Major genitourinary surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Major orthopaedic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Brain surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lung, liver and kidney transplantation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">High-risk. Risk of cardiac complications < 5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aortic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Peripheral artery surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944420.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Surgical risk in CHF patients based on the type of surgery." ] ] 12 => array:7 [ "identificador" => "tbl0040" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Low-risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients with no known heart disease and with ≤ 2 cardiovascular risk factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intermediate-risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No known heart disease and 2 cardiovascular risk factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">High-risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">High-risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Acute coronary syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Angina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Symptomatic valvular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Complex congenital heart disease of pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cardiovascular risk factors: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Insulin-dependent diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Kidney failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age > 65 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stroke/Transitory ischaemic attack (TIA) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944430.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Surgical risk based preoperative cardiac status." ] ] 13 => array:7 [ "identificador" => "tbl0045" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Unstable angina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Congestive heart failure NYHA IV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">One-month history of new onset or worsened congestive heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Significant arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3rd degree AV block \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Significant ventricular arrhythmias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Supraventicular arrhythmias including atrial fibrillation with rapid ventricular response \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Symptomatic bradycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Suspicion of prior ventricular tachycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Significant valvular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Significant aortic stenosis, with mean gradient > 40 mm Hg or valve area < 1 cm2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Symptomatic mitral stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944417.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cardiological situation in which the patients must be evaluated using specific cardiological protocols." ] ] 14 => array:7 [ "identificador" => "tbl0050" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Optimised monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Invasive arterial pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Central venous pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• CO, SV seen on arterial waveform \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Swan-Ganz catheter \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Transthoracic electrical impedance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Partial CO2rebreathing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Oesophageal Doppler \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Echocardiagraphy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Parameters measured \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Static parameters \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Pressures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Central venous pressure (CVP) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Pulmonary wedge pressure (PWP) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Volumes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Right ventriclular end-diastolic pressure index (RVEDI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Left ventriclular end-diastolic pressure index (LVEDI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• End-diastolic volume index (EDVI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Intrathoracic total blood volume index (ITBI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Dynamic parameters \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Venous saturation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• SvO2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• SvO2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Heart lung interaction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Perfusion pressure variation (PPV) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Systolic pressure variation (SPV) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Systolic volume variation (SVV) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944436.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommended monitoring in patients undergoing preoperative haemodynamic optimisation with inotropic drugs such as levosimendan." ] ] 15 => array:7 [ "identificador" => "tbl0055" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1. Diminished preload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Hypovolaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• PEEP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Pneumothorax \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2. Increased afterload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Vasoconstriction: hypothermia; sympathetic stimulation; poorly controlled hypetension; pain; administration of alpha mimetics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Inadequately controlled obstructive hypertrophic cardiomyopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Uncontrolled aortic stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prosthetic malfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3. Diminished contractility \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Preoperative ventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Myocardial oedema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Myocardial ischaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Hypoxia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Severe acidosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Overdose of beta-blockers or other antiarrhythmics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4. Alterations in heart rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Bradycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Tachycardia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944441.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Most common causes of postoperative low output." ] ] 16 => array:8 [ "identificador" => "tbl0060" "etiqueta" => "Table 10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from <a class="elsevierStyleCrossRef" href="#bib1225">46</a> with changes by the authors." "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors that usually lead to rapid deterioration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors associated with more gradual deterioration \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Rapid arrhythmia or severe bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Acute coronary syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• COPD exacerbation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Mechanical complication of acute coronary syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Anaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Pulmonary embolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Kidney failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Hypertensive crisis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Non-compliance with diet/drug regimen \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Iatrogenic causes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Aortic dissection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Arrhythmia, bradycardia, conduction disorders not leading to sudden, severe change in heart rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Surgical and perioperative problems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Uncontrolled hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Peripartum cardiomyopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Hypothyroidism and hyperthyroidism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Alcohol and narcotics abuse \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944448.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Trigger factors for acute heart failure (AHF)." ] ] 17 => array:7 [ "identificador" => "tbl0065" "etiqueta" => "Table 11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Stabilise haemodynamics. Avoid hypoperfusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Improve oxygenation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Limit heart and kidney damage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Consider using mechanical circulatory support systems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Improve symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Reduce length of stay in the intensive care unit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Reduce hospital stay \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944437.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Therapeutic goals in acute postoperative heart failure." ] ] 18 => array:7 [ "identificador" => "tbl0070" "etiqueta" => "Table 12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Cardiac \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Volume overload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Acute heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Unstable angina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Acute myocardial infarction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Bronchoaspiration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Pneumonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Pulmonary embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Fat embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Bronchospasm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ COPD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Miscellaneous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Anaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Fever \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Anxiety \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Ascites with portal hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Malnutrition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Sepsis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944418.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential diagnosis of postoperative dyspnoea." ] ] 19 => array:7 [ "identificador" => "tbl0075" "etiqueta" => "Table 13" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bolus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infusion rate \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dobutamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–20μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dopamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3-5μg/kg/min (beta +) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dopamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5μg/kg/min (alfa +) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Milrinone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–75μg/kg in 10–20min<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.375–0.75μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Enoximone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5-1.0μg/kg in 5–10min<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–20μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Levosimendan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12μg/kg in 10min<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.1μg/kg/min, can be reduced to 0.05 or increased to 0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Norepinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.2–1.0μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Epinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1mg IV during resuscitation, repeated every 3–5min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05–0.5μg//kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944425.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "With caution in hypotensive patients. If bolus administration is chosen, vasopressors should be available to compensate the vasodilator effect." ] ] ] "descripcion" => array:1 [ "en" => "Positive inotropic or vasopressor drugs, or both, used to treat acute HF." ] ] 20 => array:7 [ "identificador" => "tbl0080" "etiqueta" => "Table 14" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Systolic arterial hypotension less than 90mmHg for more than 30min or, in hypertensive patients, a reduction of 30% over baseline levels maintained for more than 30minutes; hypotension is not synonymous with shock; shock is generally accompanied by severe hypotension, but some previously hypertensive patients can present the characteristic tissue perfusion abnormalities while showing “normal” arterial pressure levels. Normal tissue perfusion can be maintained with serious hypotension if compensation mechanisms are adequate. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Signs of tissue hypoperfusion (peripheral hypoperfusion due to low output and subsequent compensatory vasoconstriction) and signs of vital organ dysfunction are the most specific indications of shock, and evidenced by: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Lactic acidosis, or the presence of one or more of the following clinical criteria secondary to a sudden or gradual decrease in tissue flow. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Pallor and cold, clammy skin, piloeraction and mottled cyanosis, usually around the knees. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oliguria (urine output <20ml/h, with urine Na levels <30mequiv/l). This is a fundamental sign, although it can only be confirmed after one or 2h. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• CNS depression with altered mental status secondary to insufficient blood supply to the brain (obtundation, agitation or confusion) and intense fatigue. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Manifestations of left and/or right congestive HF: dyspnoea, rapid, shallow breathing (>30/min), rales and/or jugular venous distension. If auscultation does not show rales, hypovolaemia should be suspected (no jugular vein distension) or right ventricular infarction, cardiac tamponade or bradyarrhythmia (with jugular vein distension). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944439.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis of cardiogenic shock." ] ] 21 => array:7 [ "identificador" => "tbl0085" "etiqueta" => "Table 15" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">a. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Correct hypoxia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">b. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Administer causal therapy once the aetiology and trigger factors of the cardiogenic shock have been identified. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">c. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treat the symptoms of the main haemodynamic problems associated with the shock: control heart rate, optimise venous return, improve contractility and reduce afterload if tolerated. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">d. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Use mechanical circulatory support or balloon pump. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">e. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgery, when advisable; mainly in acute mitral valve insufficiency due to rupture of the papillary muscle, the ventricular septum, or post-infarction ventricular septal rupture. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944414.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Basic therapeutic manoeuvres in left ventricle failure." ] ] 22 => array:7 [ "identificador" => "tbl0090" "etiqueta" => "Table 16" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical situation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic manoeuvre \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Normotensive+normal heart rate</td><td class="td" title="table-entry " align="left" valign="top">IV nitroglycerine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Calcium channel blockers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Balloon pump \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Hypertension+tachycardia</td><td class="td" title="table-entry " align="left" valign="top">Analgesics and sedation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV nitroglycerine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Calcium channel blockers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Normotensive+tachycardia</td><td class="td" title="table-entry " align="left" valign="top">Analgesics and sedation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Increase preload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Hypertension+normal heart rate</td><td class="td" title="table-entry " align="left" valign="top">Analgesics and sedation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV nitroglycerine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Calcium channel blockers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alpha antagonists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Hypotension+tachycardia</td><td class="td" title="table-entry " align="left" valign="top">Increase preload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alpha antagonists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Balloon pump \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Hypotension+bradycardia</td><td class="td" title="table-entry " align="left" valign="top">Inotropes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Balloon pump \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">External pacemaker \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Hypotension+normal heart rate</td><td class="td" title="table-entry " align="left" valign="top">Increase preload \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Inotropes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alpha mimetics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Balloon pump \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944444.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Basic therapeutic manoeuvres in postoperative myocardial ischaemia." ] ] 23 => array:7 [ "identificador" => "tbl0095" "etiqueta" => "Table 17" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF>2.2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF<2.2 and HF>1.2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF<1.2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SAP<70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Norepinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adrenaline or dobutamine+norepinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adrenaline or dobutamine+norepinephrineBalloon pump or ventricular assist \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SAP<100 and SAP>70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Norepinephrine or Phenylephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adrenaline or dobutamine+norepinephrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adrenaline or dobutamine+norepinephrineBalloon pump or ventricular assist \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SAP>100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dobutamine and levosimendan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Levosimendan+adrenalineBalloon pump or ventricular assist \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944423.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Use of inotropes and ventricular assist devices according to haemodynamic status." ] ] 24 => array:7 [ "identificador" => "tbl0100" "etiqueta" => "Table 18" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Female sex \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Non-ischaemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Previous treatment (ECMO, Abiomed, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Need for high-dose vasopressors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Elevated GOT (>80U/l) and bilirubin (>2mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Severe RV dysfunction (right ventricular ejection fraction <205) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Severe tricuspid regurgitation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Elevate central venous pressure (>20mmHg) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Low right ventricular stroke work index \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Decrease in PAPm ≥10mmHg at the start of RV treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944445.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main predisposing factors for right ventricle failure." ] ] 25 => array:7 [ "identificador" => "tbl0105" "etiqueta" => "Table 19" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Inodilators \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ evosimendan (preconditioning in patients with predictive factors for RV failure 0.05–0.1μg/kg/min) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Milrinone 0.375–0.75μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">∘ Dobutamine 2–20μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• NO 4–20ppm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Prostaglandins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Oral or IV sildenafil \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Adrenaline 0.05–0.5μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Dobutamine 0.2–1.0μg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Phenylephrine \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944435.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pharmacological therapy in right ventricle failure." ] ] 26 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 2666458 ] ] 27 => array:6 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of evidence rated according to the GRADE system</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial quality of the evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality diminished if \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality improved if \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of the final evidence \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Randomised clinical trial (RCT)</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">High</td><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Study limitations:Important (−1)Very important (−2)Inconsistency:Important (−1)Very important (−2)Direct evidence:Important (−1)Very important (−2)Imprecision:Important (−1)Very important (−2)Publication bias:Highly probable (−1)</td><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Strength of association:- Scientific evidence of Strong association (RR>2 or <0.5 based on observational studies with no confounding factors) (+1).- Scientific evidence of very Strong association (RR>5 or <0.2 based on studies with no possible bias) (+2).Dose–response gradient (+1)Consideration of possible confounding factors:Possible confounding factors than could have diminished the observed effect (+1).</td><td class="td" title="table-entry " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Observational studies</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Low</td><td class="td" title="table-entry " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Very low \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944432.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Levels of evidence and grades of recommendation (GRADE)." ] ] 28 => array:5 [ "identificador" => "tbl0110" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Summary of general recommendations (only includes the strongest recommendations with the highest scientific evidence)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">The Lee index, with its six variables, should be used to assess the risk of intraoperative cardiac complications. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NT-proBNP and BNP measurements may be considered for obtaining independent prognostic information for perioperative and delayed risk of cardiac events in high-risk patients. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG is recommended for patients who have risk factor and are scheduled for intermediate- or high-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG may be considered for patients who have one or more risk factor and are scheduled for low-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG may be considered for patients who have no risk factor and are scheduled for intermediate-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stress testing may be considered for patients who have one or two clinical risk factors and are scheduled for high-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with acute ST-segment elevation myocardial infarction. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with acute myocardial infarction without ST-segment elevation and with unstable angina. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with angina refractory to appropriate medication. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for high-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce risks during the intervention. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce onset of clinical symptoms. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to prevent disease progression. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce morbidity and mortality. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Type of surgery, the surgical technique used, the urgency of the intervention (postponable or not) and the perioperative treatment given should be considered as independent risk factors for HF. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">The Lee index, with its six variables, should be used to assess the risk of intraoperative cardiac complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Laparoscopic procedures demonstrate a cardiac stress similar to that of open procedures, therefore, patients should undergo pre-operative risk assessment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">In high-risk patients, or those requiring high complexity interventions, surgery should be performed in hospitals with ample experience in the procedure. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Beta-blockers are recommended in patients with known ischaemic heart disease or myocardial ischaemia documented during preoperative stress tests. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Beta-blockers are recommended in patients scheduled for high-risk surgery (treatment should preferably be started between 30 days and 1 week pre-surgery) Objectives: HR, 60–70bpm; Sys. Pres. >100mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Continuation of beta-blockers is recommended in patients currently receiving this medication for ischaemic heart disease or HTN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative initiation of statin therapy is recommended one month, or at least one week, prior to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Perioperative administration of nitroglycerine can be considered for the prevention of adverse ischaemic events \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Administration of alpha 2 receptor agonists to reduce the risk of perioperative cardiovascular complications can be considered in vascular surgery patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Electrolyte abnormalities should be corrected before surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Continuation of aspirin during the perioperative period can be considered in patients previously receiving this medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Interruption of aspirin in patients previously receiving this medication should only be considered in difficult-to-control intraoperative haemostasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">It is recommended that noncardiac surgery be performed at least 6 weeks, and ideally 3 months, after bare metal (non eluting) stent implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">It is recommended that noncardiac surgery be performed at least 12 months after drug-eluting stent implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">In patients who have had recent balloon angioplasty, postponement of noncardiac surgery for at least 2 weeks should be considered \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prophylactic myocardial revascularization before high-risk surgery may be considered in patients with confirmed ischaemic heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prophylactic myocardial revascularization before intermediate-risk surgery in patients with confirmed ischaemic heart disease is not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Percutaneous coronary intervention or coronary artery bypass graft should be performed in accordance with prevailing CPGs on the management of stable angina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Provided surgery can be delayed without compromising patient safety, stable angina should be diagnosed and treated in accordance with prevailing CPGs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">In the follow-up of the above cases, aggressive medical treatment and myocardial revascularisation are recommended, in accordance with CPGs on management of stable angina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Control of ventricular rate in haemodynamically unstable patients with atrial fibrillation (AF) is recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Antiarrhythmic drugs are recommended in patients with sustained ventricular tachycardia (VT) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Thoracic epidural anaesthesia should be considered in patients with heart failure undergoing high-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Volatile anaesthetics are recommended for stable patients at risk of myocardial ischaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative anaemia increases mortality in patients with heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Restrictive transfusion strategies are recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Levosimendan is indicated in HF patients with low FEV1, in the absence of severe hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative levosimendan induces preconditioning in patients with low FEV1 in both cardiac and noncardiac surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Low-dose levosimendan induces myocardial preconditioning and lowers postoperative troponin levels in heart patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV diuretics should be administered to improve pulmonary congestion symptomatology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Antithrombotic prophylaxis should be carefully reviewed in these postoperative patients; it should be immediately started, if this has not already been done, in the absence of other contraindications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Non-invasive mechanical ventilation (for example, CPAP) should be the therapy of choice in patients with dyspnoea and pulmonary oedema and/or respiratory rate >20bpm. Both non-invasive and invasive mechanical ventilation reduce arterial pressure (above all, with elevated PEEP). It should be used with caution in hypertensive patients (SAP<85mmHg). Postoperative patients receiving mechanical ventilation should always be closely monitored \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV nitrates should be considered in patients with symptoms of pulmonary congestion, provided SAP is >110mmHg and in the absence of severe mitral or aortic stenosis. In the latter case, vasodilators should be administered with caution and combined with invasive arterial pressure monitoring \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mechanical circulatory support should be considered early in severely hypoperfused patients, despite the use of inotropes and with confirmation of a potentially reversible or correctable cause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Levosimendan perfusion without a loading dose should be evaluated in patients with decompensated HF. The patient should be adequately monitored; at least, ECG, non-invasive BP and SpO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Thrombolysis is recommended as an alternative to coronary intervention, although its contra-indications are similar to those of coronary intervention Risk-benefit should be evaluated individually, with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery, prostate surgery, and interventions involving the posterior chamber of the eye \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Heart bypass surgery should be performed early, but not urgently, in patients with non-ST elevation ACS in order to reduce the risk of recurrent ACS. Risk-benefit should be evaluated individually, with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery, prostate surgery, and interventions involving the posterior chamber of the eye \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Urgent heart bypass surgery should be performed in haemodynamically unstable patients with ACS. Risk-benefit should be evaluated individually, with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery, prostate surgery, and interventions involving the posterior chamber of the eye \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Early use of ACE inhibitors or ARBs is recommended in patients with LV ejection fraction ≤40% and ACS, once stabilised, in order to reduce the risk of mortality or reinfarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Early use of beta-blockers is recommended in patients with LVEF≤40% and ACS, once stabilised, in order to reduce the risk of mortality or reinfarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Electric cardioversion is recommended in all surgical patients with recent onset atrial fibrillation. The aim must be immediate restoration of sinus rhythm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Complete anticoagulation (e.g. IV heparin), in the absence of absolute contraindications for surgery, is recommended to reduce the risk of systemic arterial embolism and stroke in patients in whom sinus rhythm has not been restored \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Antibiotics for prophylaxis against endocarditis should be given to patients with valve disease or artificial valves if there is a risk of bacteraemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Invasive haemodynamic monitoring should be used in patients with moderate to severe aortic stenosis or similar severe valve disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spinal anaesthesia is very poorly tolerated in patients with severe aortic stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944438.png" ] ] ] ] ] 29 => array:6 [ "identificador" => "tbl0115" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk<1% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intermediate risk 1–5% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk>5% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Breast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Aortic and major vascular surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Carotid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral vascular surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Endocrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral arterial angioplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eye \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endovascular aneurysm repair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gynaecology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Head and neck surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reconstructive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurological/orthopaedic-major (hip and spine surgery)- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Orthopaedic-minor (knee surgery) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary renal/liver transplant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Urologic-minor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urologic-major \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944415.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Risk of myocardial infarction and cardiac death within 30 days after surgery (modified from Boersma et al.)." ] ] ] "descripcion" => array:1 [ "en" => "Surgical risk<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> estimate." ] ] 30 => array:5 [ "identificador" => "tbl0010" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Clinical questions:Need for preoperative cardiac assessmentIn patients with heart failure (HF), is preoperative cardiac assessment necessary for successful surgery?</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stabilised patients that have been correctly evaluated and treated do not need any kind of cardiac assessment before undergoing noncardiac surgery unless their heart failure symptoms have changed or they present stable angina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Weak \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944419.png" ] ] ] ] ] 31 => array:5 [ "identificador" => "tbl1113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Clinical questions:Importance of systolic and diastolic heart failure in surgical patientsIn patients with suspected HF, are there criteria for differential diagnosis and prognosis?In surgery patients with HF, is there an index to grade severity or poorer prognosis for surgery?</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">The Lee index, with its six variables, should be used to assess the risk of intraoperative cardiac complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944447.png" ] ] ] ] ] 32 => array:5 [ "identificador" => "tbl2113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Clinical questions:Diagnosis of heart failure patientsIn preoperative adult patients, does clinical suspicion of HF determine the actions of the anaesthesiologist prior to surgery?In adult surgical patients with suspicion of HF, are there specific tests to determine the pre-anaesthesia procedure?In adult surgical patients with HF, should preoperative coronary angiography be performed to assess the risk of surgery?</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NT-proBNP and BNP measurements may be considered for obtaining independent prognostic information for perioperative and delayed risk of cardiac events in high-risk patients. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Systematic sampling for biomarkers to prevent cardiac complications is not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG is recommended for patients who have risk factor and are scheduled for intermediate- or high-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG may be considered for patients who have one or more risk factor and are scheduled for low-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG may be considered for patients who have no risk factor and are scheduled for intermediate-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pre-operative ECG is not recommended for patients who have no risk factors and are scheduled for low-risk surgery. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Resting echocardiography may be considered to evaluate left ventricular function in patients scheduled for high-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Resting echocardiography to evaluate left ventricular function in asymptomatic patients is not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stress testing is recommended in patients who have three or more clinical risk factors and are scheduled for high-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stress testing may be considered for patients who have one or two clinical risk factors and are scheduled for high-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stress testing may be considered in patients scheduled for intermediate-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stress testing is not recommended in patients scheduled for low-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with acute ST-segment elevation myocardial infarction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with acute myocardial infarction without ST-segment elevation and with unstable angina \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography is recommended in patients with angina refractory to appropriate medication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for high-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for intermediate-risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative angiography in stabilised patients who are scheduled for low-risk surgery is not recommended \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Weak −Level of evidence: Low \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944428.png" ] ] ] ] ] 33 => array:5 [ "identificador" => "tbl3113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col">Clinical questions:Heart failure managementIn adult patients with HF scheduled for noncardiac surgery, does the effect of the drugs administered limit the risk?In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of drugs determine control of the symptoms?In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of drugs prevent disease progression?In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of drugs reduce morbidity and mortality?</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce risks during the intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce onset of clinical symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to prevent disease progression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative continuation of the patient's previous treatment is recommended to reduce morbidity and mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade of recommendation: Strong +Level of evidence: High \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab944446.png" ] ] ] ] ] 34 => array:5 [ "identificador" => "tbl4113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 35 => array:5 [ "identificador" => "tbl5113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 36 => array:5 [ "identificador" => "tbl6113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 37 => array:5 [ "identificador" => "tbl6013" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 38 => array:5 [ "identificador" => "tbl7113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 39 => array:5 [ "identificador" => "tbl8113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 40 => array:5 [ "identificador" => "tbl9113" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 41 => array:5 [ "identificador" => "tbl2013" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 42 => array:5 [ "identificador" => "tbl3013" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ …1] "imagenFichero" => array:1 [ …1] ] ] ] ] 43 => array:6 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">A.Preoperative risk evaluationNeed for preoperative cardiac assessment</li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0515">1.In patients with heart failure (HF), is preoperative cardiac assessment necessary for successful surgery?Risk factors and risk stratification in heart failure</li><li class="elsevierStyleListItem" id="lsti0520">2.In adult patients, what are the risk factors for HF?</li><li class="elsevierStyleListItem" id="lsti0525">3.In individuals with HF risk factors, are there functional status classification systems for stratifying preoperative risk?Importance of systolic and diastolic heart failure in surgical patients</li><li class="elsevierStyleListItem" id="lsti0530">4.In patients with suspected HF, are there criteria for differential diagnosis and prognosis?</li><li class="elsevierStyleListItem" id="lsti0535">5.In surgical patients with HF, is there an index to grade severity or poorer prognosis for surgery?Diagnosis of heart failure patients</li><li class="elsevierStyleListItem" id="lsti0540">6.In preoperative adult patients, does clinical suspicion of HF determine the actions of the anaesthesiologist prior to surgery?</li><li class="elsevierStyleListItem" id="lsti0545">7.In adult surgical patients with suspicion of HF, are there specific tests to determine the pre-anaesthesia procedure?</li><li class="elsevierStyleListItem" id="lsti0550">8.In adult surgical patients with HF, should preoperative coronary angiography be performed to assess the risk of surgery?Heart failure management</li><li class="elsevierStyleListItem" id="lsti0555">9.In adult patients with HF scheduled for noncardiac surgery, does the effect of the drugs administered limit the risk?</li><li class="elsevierStyleListItem" id="lsti0560">10.In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of certain drugs determine control of the symptoms?</li><li class="elsevierStyleListItem" id="lsti0565">11.In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of certain drugs prevent disease progression?</li><li class="elsevierStyleListItem" id="lsti0570">12.In adult patients with HF scheduled for noncardiac surgery, does the use vs. non-use of certain drugs reduce morbidity and mortality?</li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0575">B.Surgical techniques, anaesthetic techniques and monitoringSurgical techniques and surgery scheduling</li></ul><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0580">13.In adult patients with HF, does laparoscopy reduce the stress of open-heart surgery?</li><li class="elsevierStyleListItem" id="lsti0585">14.In adult patients with high risk HF, does surgery performed in specific hospitals vs. non-specialised hospitals give better results?</li><li class="elsevierStyleListItem" id="lsti0590">15.In adult patients with high risk HF, should clinical procedures be performed prior to elective surgery in order to achieve the best results?Premedication, anaesthetic techniques, monitoring</li><li class="elsevierStyleListItem" id="lsti0595">16.In patients with high risk HF, is a particular anaesthetic technique recommended for the best outcome?</li><li class="elsevierStyleListItem" id="lsti0600">17.In adult patients with HF, is the use of a particular anaesthetic indicated to prevent the risk of myocardial ischaemia?</li><li class="elsevierStyleListItem" id="lsti0605">18.In adult patients with HF, does concomitant anaemia modify the risk of morbidity and mortality?</li><li class="elsevierStyleListItem" id="lsti0610">19.In adult patients with HF and anaemia, does a restrictive transfusion strategy vs. a liberal strategy give better results?</li><li class="elsevierStyleListItem" id="lsti0615">20.In adult patients with HF, does pain management with NSAIDs vs. COX inhibitors give better results?</li><li class="elsevierStyleListItem" id="lsti0620">21.In adult patients with HF, does ECG ST segment monitoring vs. conventional ECG techniques give better detection of ischaemic cardiac events?</li><li class="elsevierStyleListItem" id="lsti0625">22.In adult patients with HF, does invasive pulmonary artery catheterisation improve intraoperative haemodynamic management?</li><li class="elsevierStyleListItem" id="lsti0630">23.In adult patients with HF associated with myocardial ischaemia or valve disease, does TEE monitoring improve intraoperative haemodynamic management?</li></ul><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0635">C.Preoperative pharmacological risk reductionBeta-blockers</li></ul><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0640">24.In adult patients with HF, are beta-blockers recommended vs. non-fixed dose combinations in noncardiac surgery?</li><li class="elsevierStyleListItem" id="lsti0645">25.In adult patients with HF, should beta-blockers be maintained vs. suspended to stabilise ischaemic heart disease, hypertension or arrhythmia?</li><li class="elsevierStyleListItem" id="lsti0650">26.In adult patients with HF, are preoperative beta-blockers recommended in intermediate- or low-risk noncardiac surgery?Statins</li><li class="elsevierStyleListItem" id="lsti0655">27.In adult patients with HF, should statins be used in the preoperative period vs. the perioperative and postoperative period, in noncardiac surgery?</li><li class="elsevierStyleListItem" id="lsti0660">28.In adult patients with HF, is continuation of statins recommended vs. non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery?Nitrates</li><li class="elsevierStyleListItem" id="lsti0665">29.In adult patients with HF, should perioperative nitrates be given to prevent ischaemic events in noncardiac surgery?Angiotensin-converting-enzyme inhibitors (ACE inhibitors)</li><li class="elsevierStyleListItem" id="lsti0670">30.In adult patients with HF, is continuation of ACE inhibitors recommended vs. non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery to prevent decompensation or LV systolic dysfunction?</li><li class="elsevierStyleListItem" id="lsti0675">31.In adult patients with HF, are ACE inhibitors recommended vs. non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery?</li><li class="elsevierStyleListItem" id="lsti0680">32.In adult patients with HF, are ACE inhibitors recommended vs. suspension of ACEs in hypertensive patients?Calcium channel blockers</li><li class="elsevierStyleListItem" id="lsti0685">33.In adult patients with HF, are perioperative calcium channel blockers recommended vs. non-fixed dose combinations to control ischaemic events in noncardiac surgery?</li><li class="elsevierStyleListItem" id="lsti0690">34.In adult patients with HF, are preoperative calcium channel blockers recommended vs. beta-blockers in noncardiac surgery?</li><li class="elsevierStyleListItem" id="lsti0695">35.In adult patients with HF, are preoperative calcium channel blockers recommended vs. non-fixed dose combinations in high-risk noncardiac surgery to prevent cardiovascular complications?Alpha-2 agonists</li><li class="elsevierStyleListItem" id="lsti0700">36.In adult patients with HF, are preoperative alpha-2 agonists recommended vs. non-fixed dose combinations in noncardiac surgery to prevent cardiovascular complications?Diuretics</li><li class="elsevierStyleListItem" id="lsti0705">37.In adult patients with HF, should perioperative diuretic treatment be continued vs. suspended during noncardiac surgery to prevent postoperative complications?Aspirin (ASA)</li><li class="elsevierStyleListItem" id="lsti0710">38.In adult patients with HF, should perioperative ASA be continued vs. suspended to prevent postoperative complications in noncardiac surgery?</li></ul><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0715">D.Preoperative revascularisation as a risk reduction strategyPlanning noncardiac surgery in stabilised patients with prior revasculisation</li></ul><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0720">39.In stabilised adult patients with CABG up to five years previously, should surgery be delayed?</li><li class="elsevierStyleListItem" id="lsti0725">40.Following placement of bare metal stents in adult patients, should noncardiac surgery be delayed?</li><li class="elsevierStyleListItem" id="lsti0730">41.Following placement of drug-eluting stents in adult patients, should noncardiac surgery be delayed?</li><li class="elsevierStyleListItem" id="lsti0735">42.Following balloon angioplasty n adult patients, should noncardiac surgery be delayed?</li><li class="elsevierStyleListItem" id="lsti0740">43.In adult patients with unstable angina, needing urgent surgery, should antiplatelet and/or anticoagulant therapy be suspended?Prophylactic revascularisation in stablised patients</li><li class="elsevierStyleListItem" id="lsti0745">44.In adult patients with HF and stabilised ischaemic heart disease, should the intervention be delayed vs. coronary revascularisation performed for a successful surgical outcome?</li><li class="elsevierStyleListItem" id="lsti0750">45.In adult patients with HF and stabilised ischaemic heart disease, should high-risk interventions be delayed vs. coronary revascularisation performed for a successful surgical outcome?Prophylactic revascularisation in patients with unstable ischaemic heart disease</li><li class="elsevierStyleListItem" id="lsti0755">46.In adult patients with unstable ischaemic heart disease, should the intervention be delayed vs. preoperative diagnosis and treatment for a successful surgical outcome?</li><li class="elsevierStyleListItem" id="lsti0760">47.In adult patients with a potentially fatal and concomitant surgical episode of acute coronary syndrome (ACS), should surgery be delayed vs. ACS treated?</li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0765">E.Therapeutic strategy for arrhythmiasSupraventricular arrhythmia</li></ul><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0770">48.In haemodynamically stable adult patients with AF, for successful surgery, should the ventricular rate be monitored?</li><li class="elsevierStyleListItem" id="lsti0775">49.In adult patients with SV arrhythmia, should antiarrhythmic medication be maintained during the preoperative and perioperative stages?</li><li class="elsevierStyleListItem" id="lsti0780">50.In haemodynamically unstable adult patients with SV arrhythmia, should electric cardioversion be performed vs. vagal manoeuvres or medication before surgery?Ventricular arrhythmias</li><li class="elsevierStyleListItem" id="lsti0785">51.In adult patients with chronic ventricular arrhythmia, should preoperative and perioperative antiarrhythmic medication be maintained?</li><li class="elsevierStyleListItem" id="lsti0790">52.In haemodynamically unstable adult patients with chronic ventricular arrhythmia, should antiarrhythmic medication be maintained vs. electric cardioversion performed?Implantable devices</li><li class="elsevierStyleListItem" id="lsti0795">53.In adult patients with arrhythmia, should devices be implanted preoperatively vs. postoperatively?</li></ul><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0800">F.Use of inotropic drugsDopamine, dobutamine, phosphodiesterase III inhibitors</li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0805">54.In adult patients with HF, is intraoperative dopamine recommended vs. other inotropic drugs?Levosimendan</li><li class="elsevierStyleListItem" id="lsti0810">55.In adult patients with HF, is intraoperative levosimendan recommended vs. other medication?</li><li class="elsevierStyleListItem" id="lsti0815">56.In adult patients with HF, is levosimendan recommended vs. other medication for intraoperative myocardial preconditioning?</li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0820">G.Therapeutic strategies for acute postoperative HFPatients with pulmonary congestion/pulmonary oedema without shock</li></ul><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0825">57.In adult patients with pulmonary congestion/pulmonary oedema without shock, are inotropes recommended vs. other drugs (vasodilators, diuretics, opioids) to improve the clinical situation?</li><li class="elsevierStyleListItem" id="lsti0830">58.In adult patients with pulmonary congestion/pulmonary oedema without shock, should high FiO2 be administered by spontaneous ventilation vs. mechanical ventilation to improve the clinical situation?</li><li class="elsevierStyleListItem" id="lsti0835">59.In adult patients with pulmonary congestion/pulmonary oedema without shock, is early antithrombotic prophylaxis recommended vs. delayed antithrombotic prophylaxis to prevent thromboembolic complications?Patients with low output, hypotension, hypoperfustion or shock</li><li class="elsevierStyleListItem" id="lsti0840">60.In adult patients with low output, hypotension, hypoperfusion or shock, is cardioversion recommended vs. medication to restore sinus rhythm and haemodynamics?</li><li class="elsevierStyleListItem" id="lsti0845">61.In adult patients with low output, hypotension, hypoperfusion or shock, are inotropes recommended vs. other medication to improve the clinical situation?</li><li class="elsevierStyleListItem" id="lsti0850">62.In adult patients with low output, hypotension, hypoperfusion or shock, are mechanical circulatory support systems recommended vs. medication to restore haemodynamics and tissue perfusion?</li><li class="elsevierStyleListItem" id="lsti0855">63.In adult patients with low output, hypotension, hypoperfusion or shock, is cardioversion recommended vs. medication to restore sinus rhythm and haemodynamics?Surgical patients with acute coronary syndrome (ACS)</li><li class="elsevierStyleListItem" id="lsti0860">64.In adult surgical patients with ACS, is urgent coronary intervention recommended vs. revascularisation to reduce the area of necrosis?</li><li class="elsevierStyleListItem" id="lsti0865">65.In adult surgical patients with ACS, are there alternative treatments to urgent coronary intervention or revascularisation to reduce the area of necrosis?</li><li class="elsevierStyleListItem" id="lsti0870">66.In adult surgical patients with ACS, are there alternative drug therapies to reduce secondary morbidity and mortality?Patients with AF with rapid ventricular response</li><li class="elsevierStyleListItem" id="lsti0875">67.In adult surgical patients with ACS, is electric cardioversion recommended vs. medical cardioversion for rapid restoration of the sinus rhythm?Patients with severe bradycardia</li><li class="elsevierStyleListItem" id="lsti0880">68.In adult surgical patients with ACS and severe bradycardia, are external pacemakers indicated to restore haemodynamic stability?</li></ul><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0885">H.Strategy in patients with valve disease needing noncardiac surgery</li></ul><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0890">69.In adult patients with valve disease, are there specific monitoring protocols to prevent perioperative complication?</li><li class="elsevierStyleListItem" id="lsti0895">70.In adult patients with valve disease, are there pre-noncardiac surgery therapeutic alternatives to optimise haemodynamics?</li><li class="elsevierStyleListItem" id="lsti0900">71.In adult patients with valve disease, are there specific optimal anaesthetic techniques vs. other poorly tolerated anaesthetic techniques?</li></ul><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0905">I.Strategy in patients with pulmonary hypertension (PH)</li></ul><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0910">72.In adult patients with PH, should existing medication be maintained vs. administration of other medication?</li><li class="elsevierStyleListItem" id="lsti0915">73.In adult patients with PH, should specific anaesthesia monitoring techniques be used to ensure the best possible surgical conditions?</li><li class="elsevierStyleListItem" id="lsti0920">74.In adult patients with PH, are there anaesthetic techniques vs. surgical interventions that are poorly tolerated?</li></ul>" ] "descripcion" => array:1 [ "en" => "Clinical questions (PICO format)" ] ] 44 => array:5 [ "identificador" => "tb0010" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>" ] ] 45 => array:5 [ "identificador" => "tb0015" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => 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Consensus statement

Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery

J. Alvarez Escuderoa, J.M. Calvo Vecinoa,b,

Corresponding author

jmaria.calvo@salud.madrid.org

Corresponding author.

, S. Veirasc, R. Garcíad, A. Gonzáleze

a Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain

b Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain

c Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain

d Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain

e Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain

Working Group of the CPG

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">This clinical practice guideline answers to clinical questions concerning this process and is mainly aimed at professionals involved in health care for patients with heart failure before noncardiac surgery to reduce the anaesthetic-surgical risk&#44; with the aim of provide them with appropriate management and treatment of this pathology tools&#44; as well as facilitate coordination between the field of Hospital Care and Surgical Center&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This guide is the result of hard work by a group of health professionals from different autonomous communities&#44; specialists in anesthesiology&#44; cardiology&#44; internal medicine&#44; biostatistics&#44; nursing and Methodology of Spain&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia><elsevierMultimedia ident="tb0010"></elsevierMultimedia><elsevierMultimedia ident="tb0015"></elsevierMultimedia></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="par0590" class="elsevierStylePara elsevierViewall">In 1977&#44; Goldman advised against surgery in patients with heart failure &#40;HF&#41;&#46; Nowadays&#44; however&#44; these patients are regularly scheduled for surgery in our hospitals&#44; and the trend is likely to increase in the future&#46; This is because although incidence of cardiac death is falling&#44; the prevalence of ischaemic heart disease&#44; atrial fibrillation &#40;AF&#41;&#44; and cardiovascular risk factors such as diabetes mellitus or HTN is increasing&#44; and will no doubt create a greater demand for surgery in these patients in the near future&#46;</p><p id="par0595" class="elsevierStylePara elsevierViewall">It is widely accepted that between 1&#37; and 6&#37; of patients undergoing major surgery have heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib1000"><span class="elsevierStyleSup">1&#8211;50</span></a> This percentage is expected to increase&#44; because the average age of surgical patients requiring major surgery is rising&#44; and because the prevalence of HF with preserved EF increases with age&#46;</p><p id="par0600" class="elsevierStylePara elsevierViewall">Ischaemic heart disease is traditionally associated with increased morbidity and mortality in patients undergoing noncardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1250"><span class="elsevierStyleSup">51&#8211;54</span></a> However&#44; we now know that HF is the primary intraoperative risk factor in cardiovascular disease patients undergoing noncardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1050"><span class="elsevierStyleSup">11&#44;24&#44;31&#44;32&#44;42&#44;55&#8211;58</span></a></p><p id="par0605" class="elsevierStylePara elsevierViewall">Despite its undoubted importance&#44; HF is frequently underestimated&#44; possibly due to epidemiological reasons&#46; Let us not forget that HF is the third cause of death &#40;15&#37;&#41; from cardiovascular disease after ischaemic heart disease and cerebrovascular disease&#44; which together are responsible for 60&#37; of deaths&#46; The real importance of HF&#44; however&#44; is underestimated&#44; because many patients that die from ischaemic heart disease or cerebrovascular disease also have HF&#44; which to a certain extent contributes to their death&#46;<a class="elsevierStyleCrossRef" href="#bib1290"><span class="elsevierStyleSup">59</span></a></p><p id="par0610" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">References&#58;</span><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0615" class="elsevierStylePara elsevierViewall">Goldman L&#44; Caldera DL&#44; Nussbaum SR&#44; Southwick FS&#44; Krogstad D&#44; Murray B&#44; et al&#46; Multifactorial index of cardiac risk in noncardiac surgical procedures&#46; N Engl J Med&#46; 1977&#59;297&#58;845&#8211;50&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0620" class="elsevierStylePara elsevierViewall">Mangano DT&#46; Perioperative cardiac morbidity&#46; Anesthesiology&#46; 1990&#59;72&#58;153&#8211;84&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0625" class="elsevierStylePara elsevierViewall">Mangano DT&#44; Layug EL&#44; Wallace A&#44; Tateo I&#46; Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery&#46; Multicenter Study of Perioperative Ischaemia Research Group&#46; N Engl J Med&#46; 1996&#59;335&#58;1713&#8211;20&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0630" class="elsevierStylePara elsevierViewall">Lee TH&#44; Marcantonio ER&#44; Mangione CM&#44; Thomas EJ&#44; Polanczyk CA&#44; Cook EF&#44; et al&#46; Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery&#46; Circulation&#46; 1999&#59;100&#58;1043&#8211;9&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0635" class="elsevierStylePara elsevierViewall">Wiklund RA&#44; Stein HD&#44; Rosenbaum SH&#46; Activities of daily living and cardiovascular complications following elective&#44; noncardiac surgery&#46; Yale J Biol Med&#46; 2001&#59;74&#58;75&#8211;87&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0640" class="elsevierStylePara elsevierViewall">Eagle KA&#44; Berger PB&#44; Calkins H&#44; Chaitman BR&#44; Ewy GA&#44; Fleischmann KE&#44; et al&#46; ACC&#47;AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary a report of the American College of Cardiology&#47;American Heart Association Task Force on Practice Guidelines &#40;Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery&#41;&#46; Circulation&#46; 2002&#59;105&#58;1257&#8211;67&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0645" class="elsevierStylePara elsevierViewall">Aurigemma GP&#44; Gaasch WH&#46; Clinical practice&#46; Diastolic heart failure&#46; N Engl J Med&#46; 2004&#59;351&#58;1097&#8211;105&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0650" class="elsevierStylePara elsevierViewall">Hernandez AF&#44; Whellan DJ&#44; Stroud S&#44; Sun JL&#44; O&#8217;Connor CM&#44; Jollis JG&#46; Outcomes in heart failure patients after major noncardiac surgery&#46; J Am Coll Cardiol&#46; 2004&#59;44&#58;1446&#8211;53&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0655" class="elsevierStylePara elsevierViewall">Gonseth J&#44; Guallar-Castill&#243;n P&#44; Banegas JR&#44; Rodr&#237;guez-Artalejo F&#46; The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure&#58; a systematic review and meta-analysis of published reports&#46; Eur Heart J&#46; 2004&#59;25&#58;1570&#8211;95&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0660" class="elsevierStylePara elsevierViewall">McMurray JJ&#44; O&#8217;Meara E&#46; Treatment of heart failure with spironolactone &#8211; trial and tribulations&#46; N Engl J Med&#46; 2004&#59;351&#58;526&#8211;8&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0665" class="elsevierStylePara elsevierViewall">Mangano DT&#46; Perioperative medicine&#58; NHLBI working group deliberations and recommendations&#46; J Cardiothorac Vasc Anesth&#46; 2004&#59;18&#58;1&#8211;6&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0670" class="elsevierStylePara elsevierViewall">Flather MD&#44; Shibata MC&#44; Coats AJ&#44; Van Veldhuisen DJ&#44; Parkhomenko A&#44; Borbola J&#44; et al&#46; Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure &#40;SENIORS&#41;&#46; Eur Heart J&#46; 2005&#59;26&#58;215&#8211;25&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0675" class="elsevierStylePara elsevierViewall">Hunt SA&#44; ACC&#47;AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult&#58; a report of the American College of Cardiology&#47;American Heart Association Task Force on Practice Guidelines &#40;Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure&#41;&#46; J Am Coll Cardiol&#46; 2005&#59;46&#58;e1&#8211;82&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0680" class="elsevierStylePara elsevierViewall">Bhatia RS&#44; Tu JV&#44; Lee DS&#44; Austin PC&#44; Fang J&#44; Haouzi A&#44; et al&#46; Outcome of heart failure with preserved ejection fraction in a population-based study&#46; N Engl J Med&#46; 2006&#59;355&#58;260&#8211;9&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0685" class="elsevierStylePara elsevierViewall">Fox K&#44; Garcia MA&#44; Ardissino D&#44; Buszman P&#44; Camici PG&#44; Crea F&#44; et al&#46; Guidelines on the management of stable angina pectoris&#58; executive summary&#58; the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology&#46; Eur Heart J&#46; 2006&#59;27&#58;1341&#8211;81&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0690" class="elsevierStylePara elsevierViewall">Boersma E&#44; Kerta I MD&#44; Schouten O&#44; Bax JJ&#44; Noordzij P&#44; Steyerberg EW&#44; Schinkel AF&#44; et al&#46; Perioperative cardiovascular mortality in noncardiac surgery&#58; validation of the Lee cardiac risk index&#46; Am J Med&#46; 2005&#59;118&#58;1134&#8211;41&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0695" class="elsevierStylePara elsevierViewall">Don Poldermans et al&#46;&#44; Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology &#40;ESC&#41; and endorsed by the European Society of Anaesthesiology &#40;ESA&#41;&#46; Eur&#46; J&#46; Anaesthesiol&#46; 2010&#59;27&#58;92&#8211;137&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0015">Scope and objectives</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0020">Objectives</span><p id="par0700" class="elsevierStylePara elsevierViewall">This clinical practice guideline &#40;CPG&#41; is intended to serve as a tool to reduce uncertainty and variability in the detection&#44; treatment and control of heart failure patients requiring noncardiac surgery&#46; The aim of this CPG is to&#58;<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">2&#46;1&#46;1&#46;</span><p id="par0705" class="elsevierStylePara elsevierViewall">Review current practice in connection with the clinical problem and make a series of evidence-based recommendations &#40;Table of General Recommendations&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">2&#46;1&#46;2&#46;</span><p id="par0710" class="elsevierStylePara elsevierViewall">Draw up a strategy for reducing anaesthesia and surgical risk in these patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Risk reduction&#44; therefore&#44; will be the central theme of these recommendations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;1&#46;3&#46;</span><p id="par0715" class="elsevierStylePara elsevierViewall">Unlike other clinical guidelines&#44; this CPG will consider intra- and postoperative manoeuvres and treatment to be equally important as preoperative therapy and risk assessment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">2&#46;1&#46;4&#46;</span><p id="par0720" class="elsevierStylePara elsevierViewall">Facilitate decision-making in pre-&#44; intra-&#44; and postoperative management of HF patients requiring&#44; or having undergone&#44; noncardiac surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">2&#46;1&#46;5&#46;</span><p id="par0725" class="elsevierStylePara elsevierViewall">Provide patients and carers with useful information on evidence-based interventions that can facilitate shared decision-making and enable them to become actively involved in the process of care&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0025">Target population</span><p id="par0730" class="elsevierStylePara elsevierViewall">This guideline is aimed at any adult individual with risk factors or a diagnosis of heart failure &#40;HF&#41;&#46; The term HF will be used through this clinical practice guideline&#46; HF encompasses both primary heart failure and secondary heart failure treated in the same way as primary HF&#46; It will not deal with specific management of secondary causes leading to HF&#46; The guideline does not include the paediatric population because the general characteristics of HF &#40;causes&#44; treatment and evolution&#41; differ in these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0030">Clinical areas included in the guideline</span><p id="par0735" class="elsevierStylePara elsevierViewall">This guideline addresses&#58;<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0740" class="elsevierStylePara elsevierViewall">Overview of HF<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8728;</span><p id="par0745" class="elsevierStylePara elsevierViewall">Diagnosis of HF</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8728;</span><p id="par0750" class="elsevierStylePara elsevierViewall">Management of HF</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0755" class="elsevierStylePara elsevierViewall">Preoperative risk reduction in HF patients scheduled for noncardiac surgery&#46;<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8728;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Risk assessment and risk indices</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8728;</span><p id="par0765" class="elsevierStylePara elsevierViewall">Alternative therapies</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8728;</span><p id="par0770" class="elsevierStylePara elsevierViewall">Preoperative revascularisation</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8728;</span><p id="par0775" class="elsevierStylePara elsevierViewall">Arrhythmia</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8728;</span><p id="par0780" class="elsevierStylePara elsevierViewall">Implantable devices and surgery</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0785" class="elsevierStylePara elsevierViewall">Intraoperative risk reduction in HF patients scheduled for noncardiac surgery&#46;<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8728;</span><p id="par0790" class="elsevierStylePara elsevierViewall">Monitoring</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8728;</span><p id="par0795" class="elsevierStylePara elsevierViewall">Haemodynamic optimisation</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8728;</span><p id="par0800" class="elsevierStylePara elsevierViewall">Conditioning and its role in risk reduction</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8728;</span><p id="par0805" class="elsevierStylePara elsevierViewall">Remote ischaemic conditioning</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8728;</span><p id="par0810" class="elsevierStylePara elsevierViewall">Pharmacological conditioning</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0815" class="elsevierStylePara elsevierViewall">Risk-reducing anaesthetic techniques</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0820" class="elsevierStylePara elsevierViewall">Postoperative risk reduction strategy<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8728;</span><p id="par0825" class="elsevierStylePara elsevierViewall">Pain</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8728;</span><p id="par0830" class="elsevierStylePara elsevierViewall">Hypothermia and hypoxia</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8728;</span><p id="par0835" class="elsevierStylePara elsevierViewall">Acute postoperative HF<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0840" class="elsevierStylePara elsevierViewall">Postoperative hypotension&#47;hypertension</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0845" class="elsevierStylePara elsevierViewall">Postoperative low cardiac output syndrome</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0850" class="elsevierStylePara elsevierViewall">Acute heart failure&#44; left ventricular failure&#44; and cardiogenic pulmonary oedema</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0855" class="elsevierStylePara elsevierViewall">Cardiogenic shock</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0860" class="elsevierStylePara elsevierViewall">Myocardial ischaemia and acute myocardial infarction</p></li></ul></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8226;</span><p id="par0865" class="elsevierStylePara elsevierViewall">Specific pathologies in heart failure patients<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8728;</span><p id="par0870" class="elsevierStylePara elsevierViewall">Valve disease</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8728;</span><p id="par0875" class="elsevierStylePara elsevierViewall">Hypertension</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8728;</span><p id="par0880" class="elsevierStylePara elsevierViewall">Right ventricular failure&#46; Right-sided heart failure</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8728;</span><p id="par0885" class="elsevierStylePara elsevierViewall">Pulmonary arterial hypertension</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8728;</span><p id="par0890" class="elsevierStylePara elsevierViewall">Heart failure and sepsis</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8728;</span><p id="par0895" class="elsevierStylePara elsevierViewall">Heart failure and renal replacement therapy</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8728;</span><p id="par0900" class="elsevierStylePara elsevierViewall">Mechanical ventilation in heart failure patients</p></li></ul></p></li></ul></p><p id="par0905" class="elsevierStylePara elsevierViewall">This guideline DOES NOT address&#58;<ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8226;</span><p id="par0910" class="elsevierStylePara elsevierViewall">Structural heart disease not leading to HF&#44; and management of these diseases in surgical patients</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8226;</span><p id="par0915" class="elsevierStylePara elsevierViewall">Coronary disease not leading to HF&#44; and management of these diseases in surgical patients</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0920" class="elsevierStylePara elsevierViewall">Other cardiovascular disorders not leading to HF&#44; and management of these disorders in surgical patients</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8226;</span><p id="par0925" class="elsevierStylePara elsevierViewall">Congenital coronary disease leading or not leading to HF in surgical patients</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8226;</span><p id="par0930" class="elsevierStylePara elsevierViewall">Evaluation of the use of resources and the cost of treatment</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0035">Target healthcare area</span><p id="par0935" class="elsevierStylePara elsevierViewall">This guideline is for use in the Spanish National Health System&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0040">Target users</span><p id="par0940" class="elsevierStylePara elsevierViewall">This guideline is aimed at specialists in anaesthesiology and critical care&#44; cardiology&#44; nursing and internal medicine involved in the care of heart failure patients scheduled for noncardiac surgery&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0045">Methodology</span><p id="par0945" class="elsevierStylePara elsevierViewall">This clinical practice guideline has been drawn up in accordance with the Methodology Handbook for Developing Clinical Practice Guidelines &#40;2007&#41;&#46; The &#8220;Quality of evidence and grades of recommendation&#8221; system mentioned earlier in this guideline will be explained in more detail&#46; Additional information on the methodology used to develop the CPG is available at <a href="http://www.sedar.es/">www&#46;sedar&#46;es</a> &#40;critical appraisal tools for the studies selected and summary of findings tables&#41;&#46;</p><p id="par0950" class="elsevierStylePara elsevierViewall">Generally speaking&#44; the work was carried out in the following stages&#58;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0050">Creation of the task force</span><p id="par0955" class="elsevierStylePara elsevierViewall">The group in charge of drawing up the guideline is formed of specialists in the fields of anaesthesiology and critical care&#44; internal medicine&#44; intensive care&#44; cardiology and nursing&#44; and a specialist in methodology from the Spanish Society of Anaesthesiology&#44; Critical Care and Pain Therapy&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0055">Formulation of clinical questions</span><p id="par0960" class="elsevierStylePara elsevierViewall">The questions were formulated according to the PICO &#40;population&#44; intervention&#44; comparison and outcome&#41; format&#44; and discussed during a meeting of the members of the task force&#46; During the meeting&#44; the group arranged the CPG into different sections and prioritised the questions on the basis of the objectives&#44; scope&#44; target population&#44; clinical area and target users of the CPG&#46;</p><p id="par0965" class="elsevierStylePara elsevierViewall">The benefits and safety of the interventions included in the guideline were evaluated by prioritising the key outcomes sought by patients&#46; In terms of benefit&#44; the main outcome was a successful intervention &#40;successful surgery with no heart failure-related complications&#41;&#59; in terms of safety&#44; it was the adverse effect of the intervention&#46; Some questions included other&#44; more specific key outcomes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0060">Literature search</span><p id="par0970" class="elsevierStylePara elsevierViewall">A preliminary search was made for CPGs&#44; systematic reviews &#40;SR&#41; and other key summaries&#44; as well as health technology assessment reports&#44; in the scientific literature&#46; At this stage&#44; the following online databases were searched&#58;<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8226;</span><p id="par0975" class="elsevierStylePara elsevierViewall">NHS Evidence</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</span><p id="par0980" class="elsevierStylePara elsevierViewall">Cochrane Database of Systematic Reviews &#40;The Cochrane Library&#41;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8226;</span><p id="par0985" class="elsevierStylePara elsevierViewall">Database of Abstracts of Reviews of Effects &#40;DARE&#41;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0990" class="elsevierStylePara elsevierViewall">Health Technology Assessment &#40;HTA&#41; Database</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0995" class="elsevierStylePara elsevierViewall">MEDLINE &#40;through PubMed&#41;</p></li></ul></p><p id="par1000" class="elsevierStylePara elsevierViewall">During the second stage&#44; databases were searched for specific studies that would contribute updated information to existing relevant SRs and answer questions not addressed by studies retrieved in the first stage&#46; Randomised clinical trials &#40;RCS&#41; and observational studies &#40;risk factor and screening issues&#41; were mainly retrieved&#46; The foregoing searches were conducted in MEDLINE and The Cochrane Central Register of Controlled Trials&#46;</p><p id="par1005" class="elsevierStylePara elsevierViewall">A specific search was made of the MEDLINE &#40;Pubmed&#41; database for information for the values and preferences section&#46;</p><p id="par1010" class="elsevierStylePara elsevierViewall">The searches performed were not limited by language&#46; Documents published up to and including 30 September 2013 &#40;<a class="elsevierStyleCrossRef" href="#sec0455">Annex 1</a>&#58; search strategies&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0065">Study selection and evaluation of the quality of the evidence</span><p id="par1015" class="elsevierStylePara elsevierViewall">Prior to selection&#44; the titles and abstracts of studies on the benefits and safety of surgery were screened for relevance to the questions to be addressed in the CPG&#46; The full text of studies considered relevant was then evaluated for quality before being included in the CPG &#40;additional material available at <a href="http://www.sedar.es/">www&#46;sedar&#46;es</a>&#58; <span class="elsevierStyleItalic">evaluaci&#243;n de la calidad de los estudios individuales de la GPC</span> &#91;only in Spanish&#93;&#41;&#46; Only studies of the highest quality reporting target outcomes were chosen &#40;low risk of bias&#41;&#46; Systematic reviews&#44; followed by randomised clinical trials&#44; were prioritised&#46; In the case of randomised clinical trial&#44; the summary of findings &#40;meta-analysis&#41; was included wherever possible&#46;</p><p id="par1020" class="elsevierStylePara elsevierViewall">The quality of the evidence presented was evaluated according to the criteria established by the international GRADE group &#40;Grading of Recommendations of Assessment Development and Evaluations&#41; &#40;Alonso-Coello&#44; 2013&#41;&#46; The quality of the available body of evidence was evaluated for each outcome included in each clinical question&#46; The following factors were taken into account&#58; risk of bias&#44; consistency of findings from different studies&#44; availability of direct evidence&#44; accuracy of effect estimates&#44; and publication bias&#46; In the case of observational studies&#44; the following factors were also taken into account&#58; effect sizes&#44; dose&#8211;response correlation&#44; impact of confounding factors on results&#46; Following the evaluation process&#44; the quality of evidence for each outcome was ranked as high&#44; moderate&#44; low or very low&#46;</p><p id="par1025" class="elsevierStylePara elsevierViewall">It is interesting to note that for most of the questions in the CPG no information on the effect of interventions on disease progression was found&#46; Most of the studies identified evaluated myocardial ischaemia&#44; and not heart failure&#44; as a measure of the effectiveness of interventions designed to treat heart disease&#46; Ischaemia&#44; therefore&#44; is a surrogate measure for disease progression and associated complications&#59; being an indirect measurement&#44; therefore&#44; the quality of this outcome was relatively low&#44; while that of HF was relatively high&#46;</p><p id="par1030" class="elsevierStylePara elsevierViewall">With respect to patient values and preferences&#44; studies retrieved from the &#215; were initially screened by title and abstract&#44; and those that analysed useful health status values in heart failure patients were chosen&#46; Systematic reviews were initially prioritised&#44; followed by individual studies&#46; A narrative synthesis was made of the main findings&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0070">Formulation of recommendations</span><p id="par1035" class="elsevierStylePara elsevierViewall">Recommendations based on the summary of the available evidence for each clinical question&#44; were formulated according to the GRADE approach&#46; To determine the direction &#40;for or against an intervention&#41; and strength &#40;Strong or weak&#41; of recommendations&#44; the overall quality of available evidence&#44; the risk-benefit ratio of each procedure evaluated&#44; and patient values and preferences were weighed up&#46;</p><p id="par1040" class="elsevierStylePara elsevierViewall">Whenever the effect of a particular intervention on disease progression was not reported&#44; it was estimated on the basis of its effect during surgery&#46; These calculations were based on the risk of progression established in the &#8220;Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery&#8221; drafted by the The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology &#40;ESC&#41; and endorsed by the European Society of Anaesthesiology &#40;ESA&#41;&#46; European Journal of Anaesthesiology 2010&#44; 27&#58;92&#8211;137&#46; This CPG estimates the risk of cardiac events and mortality &#40;as a percentage&#41; according to the type of surgery performed&#46; Despite being an approximation&#44; this estimator was considered to more closely reflect the real effect of interventions designed to reduce the risk in question following surgery in HF patients&#46;<elsevierMultimedia ident="tb0020"></elsevierMultimedia></p><p id="par1050" class="elsevierStylePara elsevierViewall">Evidence summaries and their associated recommendation were submitted to members of the work force for consideration&#46; Decisions were taken on the basis of the depth and relevance of the research and the findings reported&#46; Following this&#44; the whole group met to discuss all the recommendations&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;6</span><span class="elsevierStyleSectionTitle" id="sect0075">External review</span><p id="par1055" class="elsevierStylePara elsevierViewall">The guideline was submitted to a multidisciplinary team for external review&#46; This team was made up of professionals from the Spanish Society of Cardiology&#44; the Spanish Society of Anaesthesiology&#44; Intensive Care and Pain Therapy&#44; the Spanish Society of Internal Medicine&#44; the Spanish Association of Surgical Nursing and the Spanish Surgery Nurse Society&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3&#46;7</span><span class="elsevierStyleSectionTitle" id="sect0080">Updates</span><p id="par1060" class="elsevierStylePara elsevierViewall">The guideline will be updated every three years&#44; or sooner if new scientific evidence emerges that would change any of the recommendations made&#46; Updates will be made to the online version of the guideline&#44; available on <a href="http://www.sedar.es/">www&#46;sedar&#46;es</a>&#46;</p><p id="par1065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">References</span><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">-</span><p id="par1070" class="elsevierStylePara elsevierViewall">Grupo de trabajo sobre GPC&#46; Elaboraci&#243;n de Gu&#237;as de Pr&#225;ctica Cl&#237;nica en el Sistema Nacional de Salud&#46; Manual Metodol&#243;gico&#46; Madrid&#58; Plan Nacional para el SNS del MSC&#46; Instituto Aragon&#233;s de Ciencias de la Salud-I&#43;CS&#59; 2007&#46; Gu&#237;as de Pr&#225;ctica Cl&#237;nica en el SNS&#58; I&#43;CS N&#176; 2006&#47;0I&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">-</span><p id="par1075" class="elsevierStylePara elsevierViewall">Alonso-Coello P&#44; Rigau D&#44; Sanabria AJ&#44; Plaza V&#44; Miravitlles M&#44; Martinez L&#46; Quality and strength&#58; The GRADE system for formulating recommendations in clinical practice guidelines&#46; Arch Bronconeumol&#46; 2013&#59;49&#40;6&#41;&#58;261&#8211;7&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">-</span><p id="par1080" class="elsevierStylePara elsevierViewall">Leske MC&#44; Heijl A&#44; Hyman L&#44; Bengtsson B&#44; Dong L&#44; Yang Z&#44; et al&#46; Predictors of long-term progression in the early manifest glaucoma trial&#46; Ophthalmology&#46; 2007&#59;114&#58;1965&#8211;72&#46;</p></li></ul></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0085">Heart failure</span><p id="par1090" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></p><p id="par1095" class="elsevierStylePara elsevierViewall">The incidence and prevalence of HF is extremely high in clinical practice&#44; and for this reason many surgical patients present this comorbidity&#46; According to estimates&#44; 20&#37; of individuals aged over 40 years in the United States are at risk for this disease&#46;<a class="elsevierStyleCrossRef" href="#bib1295"><span class="elsevierStyleSup">60</span></a></p><p id="par1100" class="elsevierStylePara elsevierViewall">HF affects between 1&#37; and 2&#37; of the world&#39;s population&#59; incidence is as high as 10&#8211;20&#37; in the over-75 group&#44; and it accounts for approximately 2&#37; of healthcare spending&#46; HF patients constitute 10&#37; of the hospital population&#44; and patients with advance HF mean survival is shorter than in many types of cancer&#46; Although survival is improving&#44; 50&#37; of patients do not survive longer that 5 years following diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">20&#44;46&#44;48</span></a></p><p id="par1105" class="elsevierStylePara elsevierViewall">Ischaemic heart disease and hypertension are responsible for 70&#37; of chronic HF cases&#46; These are followed by congenital valve defects &#40;10&#37;&#41;&#44; cardiomyopathies &#40;10&#37;&#41;&#44; and miscellaneous conditions&#44; including arrhythmia&#44; conduction disturbances&#44; conditions causing increased cardiac output &#40;anaemia&#44; sepsis&#44; Paget&#39;s disease&#44; thyrotoxicosis&#44; drug therapy&#44; use of drugs such as cocaine&#41;&#44; and diseases such as amyloidosis and sarcoidosis&#46;</p><p id="par1110" class="elsevierStylePara elsevierViewall">The American College of Cardiology and the American Heart Association &#40;ACC&#47;AHA&#41; define HF as a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood&#44; but that ultimately affects all organs and systems&#46; Tiredness&#44; fatigue&#44; dyspnoea&#44; fluid retention&#44; which may lead to pulmonary congestion and peripheral oedema are the main symptoms of HF&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 2</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib1060"><span class="elsevierStyleSup">13&#44;48</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par1115" class="elsevierStylePara elsevierViewall">The ACC&#47;AHA proposed dividing HF into four stages&#58; A&#8211;D &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 3</a>&#41;&#44; according to the extent to which the patient&#39;s physical activity is affected&#46; This functional classification is a valuable prognostic tool&#44; and can be used as a criterion in the choice of certain therapeutic decisions&#46; It is used to evaluate patient follow-up and response to treatment&#46; This system of classification differs from that used by the New York Heart Association &#40;NYHA&#41;&#44; which also divides HF into four stages&#44; but bases these on structural changes and symptoms&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par1120" class="elsevierStylePara elsevierViewall">Since HF is a syndrome&#44; this classification has become popular due to its obvious practical advantages&#46; However&#44; it also has some major drawbacks&#44; including lack of standardisation or frequent fluctuations in symptoms not associated with major changes in diet or therapy&#46; Improvements&#44; meanwhile&#44; are at times associated with therapeutic changes that must be maintained in the long term&#44; irrespective of changes in the patient&#39;s functional capacity&#46; It is essential to determine the functional capacity of HF patients in order to evaluate their preoperative level of risk&#46;<a class="elsevierStyleCrossRef" href="#bib1300"><span class="elsevierStyleSup">61</span></a></p><p id="par1125" class="elsevierStylePara elsevierViewall">In two types of heart disease&#44; namely&#44; coronary disease and valve disease&#44; pathogenesis must be correctly diagnosed&#44; since this will greatly affect the prognosis&#46;</p><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0090">Overview of the importance of systolic and diastolic heart failure in surgical patients</span><p id="par1130" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0030"></elsevierMultimedia></p><p id="par1140" class="elsevierStylePara elsevierViewall">Physicians usually distinguish between systolic and diastolic HF&#44; although the difference is not as clear as it would initially appear&#46;<a class="elsevierStyleCrossRefs" href="#bib1030"><span class="elsevierStyleSup">7&#44;46&#44;48&#44;62&#8211;65</span></a> Systolic and diastolic HF should not be considered different entities&#44;<a class="elsevierStyleCrossRef" href="#bib1325"><span class="elsevierStyleSup">66</span></a> and most HF patients show both dysfunctions both at rest and with exercise&#46;</p><p id="par1145" class="elsevierStylePara elsevierViewall">Diastolic HF occurs when patients present signs and&#47;or symptoms of HF with a left ventricular ejection fraction &#40;LVEF&#41; higher than 40&#8211;50&#37;&#44; although opinions differ on the cut-off point for preserved LVEF&#59; a left ventricular end diastolic pressure higher than 18<span class="elsevierStyleHsp" style=""></span>mmHg is consistent with significant heart failure&#44; and when restrictive diastolic dysfunction occurs&#44; there is a risk of decompensation with the slightest fluid intake or overload&#46;<a class="elsevierStyleCrossRef" href="#bib1330"><span class="elsevierStyleSup">67</span></a></p><p id="par1150" class="elsevierStylePara elsevierViewall">Within this patient group&#44; it is important to consider those with asymptomatic diastolic dysfunction&#44; which can worsen as a result of noncardiac surgery&#46;</p><p id="par1155" class="elsevierStylePara elsevierViewall">Systolic HF is defined as an entity presenting symptoms of HF with depressed LVEF&#46;</p><p id="par1160" class="elsevierStylePara elsevierViewall">Prognosis for HF is highly complex due to widely differing pathogenesis and comorbidities&#46; Depressed LVEF&#44; in other words systolic HF&#44; has the worse prognosis&#46; However&#44; recent studies&#44; albeit in medical patients not requiring surgery&#44; have shown that prognosis is similar for systolic and diastolic patients&#46;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">14</span></a></p><p id="par1165" class="elsevierStylePara elsevierViewall">Prognosis for survival in patients undergoing high or intermediate risk noncardiac or cardiac surgery is significantly worse in patients with depressed LVEF&#46;<a class="elsevierStyleCrossRefs" href="#bib1130"><span class="elsevierStyleSup">27&#44;35&#44;69</span></a> This is a key factor in noncardia surgery patients&#44; and one that not emphasised enough in most guidelines&#46; It is definitely an element to consider in risk reduction strategies&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0095">Diagnosis of heart failure patients</span><p id="par1170" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0035"></elsevierMultimedia></p><p id="par1180" class="elsevierStylePara elsevierViewall">All guidelines published to date devote considerable space to the diagnosis of HF&#46; Patients with congestive heart failure &#40;CHF&#41; are usually diagnosed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; If clinical features suggestive of CHF emerge while taking a medical history in an undiagnosed patient&#44; a preoperative cardiac evaluation must be ordered&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par1185" class="elsevierStylePara elsevierViewall">The main diagnostic texts in a patient with suspected HF are electrocardiogram &#40;ECG&#41;&#44; chest X-ray&#44; and most importantly&#44; echocardiogram &#40;echo&#41;&#46; The combination of these three techniques will&#44; in most cases&#44; establish a diagnosis of HF&#44; as shown in the algorithm in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><p id="par1190" class="elsevierStylePara elsevierViewall">Chest X-ray can detect cardiomegaly and pleural effusion&#44; but is of limited use in diagnosing HF&#46; It is&#44; however&#44; a useful differential diagnosis tool in respiratory diseases&#46; It can show signs of pulmonary congestion&#44; pleural effusion or enlargement of the cardiac silhouette&#46; However&#44; it should be borne in mind that patients with severe diastolic dysfunction do not show signs of cardiomegaly&#46;<a class="elsevierStyleCrossRefs" href="#bib1225"><span class="elsevierStyleSup">46&#44;48</span></a></p><p id="par1195" class="elsevierStylePara elsevierViewall">Echo gives real-time&#44; non-invasive information about chamber size&#44; systolic and diastolic ventricular function&#44; valvular function&#44; thickness and mobility of ventricular walls&#44; and signs of pulmonary arterial hypertension &#40;PH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1225"><span class="elsevierStyleSup">46</span></a> This information is critical for determining the level of control of the prescribed medication&#46;</p><p id="par1200" class="elsevierStylePara elsevierViewall">Since the signs and symptoms of HF are unspecific&#44; determination of natriuretic peptides &#40;BNP&#44; Nt-Pro BNP&#41;&#44; which are released during interventricular septal thickening&#44; can help in the diagnosis of HF patients&#46; Peptide levels should be determined before performing echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; since normal levels should rule out HF&#46;</p><p id="par1205" class="elsevierStylePara elsevierViewall">The usefulness of this test in the preoperative workup&#44;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">30&#44;70</span></a> however&#44; is widely debated and has yet to be clearly defined&#46; In geriatric patients&#44; or patients with kidney failure&#44; BNP levels can be elevated even in the absence of HF symptoms&#44; while in obese patients&#44; BNP levels can be falsely low&#46; Low serum natriuretic peptide levels rule out HF but not the possibility of structural heart disease&#46;</p><p id="par1210" class="elsevierStylePara elsevierViewall">Normal natriuretic peptide levels in untreated patients all but rules out heart disease&#44; and consequently the need for an echo&#46; The usual natriuretic peptide cutoff levels for excluding HF are 100<span class="elsevierStyleHsp" style=""></span>pg&#47;ml for BNP and 300<span class="elsevierStyleHsp" style=""></span>pg&#47;ml for NT-Pro BNP&#46;<a class="elsevierStyleCrossRef" href="#bib1350"><span class="elsevierStyleSup">71</span></a> In the elderly and in patients with advanced kidney failure&#44; BNP levels vary&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><p id="par1215" class="elsevierStylePara elsevierViewall">Two meta-analyses on postoperative variations in BNP in patients with HF undergoing noncardiac surgery have recently been published&#46;<a class="elsevierStyleCrossRefs" href="#bib1355"><span class="elsevierStyleSup">72&#44;73</span></a> Both studies found that increased natriuretic peptide levels post-surgery are associated with increased mortality at 30 and 180 days&#44; and increased risk of AMI&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0100">Heart failure management</span><p id="par1220" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0040"></elsevierMultimedia></p><p id="par1230" class="elsevierStylePara elsevierViewall">In this guideline&#44; we will not dwell on management of HF&#44; since this has already been discussed in several medical texts &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a>&#41;&#46; Instead&#44; we will focus on the capacity of each type of HF medication to reduce risk in patients scheduled for surgery&#44; because good HF management should not only treat symptoms&#44; but also prevent disease progression and diminish the risk of morbidity and mortality in surgical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1040"><span class="elsevierStyleSup">9&#44;46&#44;48&#44;74&#8211;76</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par1235" class="elsevierStylePara elsevierViewall">The main changes in HF treatment in the most recent European and US guidelines with respect to former recommendations are&#58; expansion of the indication for mineralocorticoid &#40;aldosterone&#41; receptor antagonists&#59; new indication for the sinus node inhibitor ivabradine&#44; such as in class NYHA II-IV chronic heart failure&#44; systolic dysfunction&#44; in patients in normal sinus rhythm and &#8805;75<span class="elsevierStyleHsp" style=""></span>bpm&#44; in association with standard treatment including betablockers&#44; or when these are contraindicated or poorly tolerated&#59; expansion of the indication for implantable cardioverter defibrillators &#40;ICD&#41;&#59; cardiac-resynchronisation therapy&#59; new information on the role of coronary revascularization in HF&#59; recognition of the growing use of ventricular assist devices&#59; and the emergence of transcatheter valve interventions&#46;<a class="elsevierStyleCrossRefs" href="#bib1225"><span class="elsevierStyleSup">46&#44;48&#44;77</span></a><elsevierMultimedia ident="tb0045"></elsevierMultimedia></p><p id="par1245" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; although ischaemic heart disease is usually associated with increased perioperative morbidity and mortality&#44; congestive HF is in fact the main perioperative risk factor in patients with cardiovascular disease undergoing noncardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1250"><span class="elsevierStyleSup">51</span></a></p><p id="par1250" class="elsevierStylePara elsevierViewall">An increasingly common added difficulty arises when the patient&#39;s asymptomatic or compensated myocardial dysfunction becomes symptomatic or decompensated due to the stress of surgery&#46;</p><p id="par1255" class="elsevierStylePara elsevierViewall">After establishing a diagnosis of HF&#44; it is important to also establish an aetiological diagnosis&#44; in case a new medical or surgical treatment can be found for the causative pathology&#46; Valve disease&#44; such as aortic stenosis&#44; is frequently corrected before performing other surgery&#46; The same is true of ischaemic heart disease&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0105">Risk evaluation in heart disease patients undergoing noncardiac surgery</span><p id="par1260" class="elsevierStylePara elsevierViewall">Strictly speaking&#44; the term heart failure should not be used in association with surgical patients&#44; because HF refers to two clearly differentiated clinical situations&#58; HF with preserved LVEF or HF with depressed LVEF&#46; As mentioned previously&#44; HF with depressed LVEF is a more high-risk situation&#46;<a class="elsevierStyleCrossRefs" href="#bib1130"><span class="elsevierStyleSup">27&#44;35&#44;68&#8211;71</span></a></p><p id="par1265" class="elsevierStylePara elsevierViewall">Estimates suggest that 0&#46;3&#37; of patients undergoing noncardiac surgery die from postoperative cardiovascular causes&#46; In the case of bypass surgery&#44; the mortality rate is as high as 2&#37;&#44; in other words&#44; seven times higher than noncardiac procedures&#46;<a class="elsevierStyleCrossRef" href="#bib1385"><span class="elsevierStyleSup">78</span></a> Boersma&#44;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">54</span></a> in a cohort of over 100&#44;000 patients undergoing noncardiac surgery&#44; reported a mortality rate of 1&#46;7&#37;&#44; or which 0&#46;5&#37; was attributed to cardiovascular causes&#46; In the DECREASE studies&#44; 3&#46;5&#37; of intermediate or high-risk surgical patients died from cardiac complications&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">79</span></a> The POISE<a class="elsevierStyleCrossRef" href="#bib1395"><span class="elsevierStyleSup">80</span></a> study reported an overall mortality rate of 2&#46;7&#37;&#44; of which 1&#46;6&#37; was from cardiovascular causes&#44; with a 4&#46;4&#37; rate of non-fatal myocardial infarction&#46;</p><p id="par1270" class="elsevierStylePara elsevierViewall">Although experts unanimously agree that CHF is a risk factor in patients undergoing noncardiac surgery&#44; it is important to remember that complications arising from this pathology depend not only on the condition of the heart&#44; but also on the type of surgery performed&#44; the technique used&#44; the level of urgency&#44; and the perioperative treatment given&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">11</span></a></p><p id="par1275" class="elsevierStylePara elsevierViewall">Surgical risk is usually stratified into three levels&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 5</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib1025"><span class="elsevierStyleSup">6&#44;32</span></a> Similarly&#44; cardiological risk is divided into three levels&#58; low&#44; intermediate and high&#44; shown in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 6</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib1025"><span class="elsevierStyleSup">6&#44;32</span></a></p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><p id="par1280" class="elsevierStylePara elsevierViewall">Emergency surgery&#44; in other words surgery that cannot be delayed&#44; is always an added risk factor&#46; The risk of emergency noncardiac surgery is estimated to be between two to five time higher than scheduled procedures&#46;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">2</span></a> Because of this high level of risk&#44; it is best to delay urgent &#40;within 48<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; or semi-elective &#40;between 48<span class="elsevierStyleHsp" style=""></span>h and 7 days after diagnosis&#41; noncardiac surgery&#46; The delay between diagnosis and surgery should be used to evaluate cardiac risk based on existing evidence whenever needed &#40;<a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>&#41; and in patients subject to preoperative haemodynamic optimisation strategies that could change the prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib1400"><span class="elsevierStyleSup">81&#44;82</span></a></p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><p id="par1285" class="elsevierStylePara elsevierViewall">The choice of surgical technique and when to perform the surgery&#44; together with the anaesthetic techniques to be discussed further on&#44; are of paramount importance&#46; Preoperative anaemia is associated with increased mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib1365"><span class="elsevierStyleSup">74&#8211;76&#44;83</span></a> and as far as possible should be treated without blood transfusion&#44; since this also increases risk in surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib1415"><span class="elsevierStyleSup">84</span></a></p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;4&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0110">Cardiac assessment in heart failure patients requiring noncardiac surgery&#46; Functional capacity&#46; Risk indices</span><p id="par1290" class="elsevierStylePara elsevierViewall">It is important to evaluate the patient&#39;s functional capacity as part of the perioperative cardiac risk evaluation&#46; Functional capacity can be evaluated on the basis of the patient&#39;s capacity to perform activities of daily living&#46; Functional capacity is usually measured in metabolic equivalents &#40;MET&#41;&#58; 1 MET is the basal metabolic rate&#44; while climbing two flights of stairs requires 4 METs&#44; and strenuous exercise requires more than 10 METs&#46; According to some authors&#44; patients that are incapable of climbing two flights of stairs &#40;&#60;4 METs&#41; have a greater risk of cardiac complications&#46; However&#44; the relationship is weak&#46; There is ample evidence&#44; however&#44; that prognosis improves in parallel with improved functional capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib1020"><span class="elsevierStyleSup">5&#44;61&#44;85</span></a></p><p id="par1295" class="elsevierStylePara elsevierViewall">Several authors have explored the various cardiac assessment tests used&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">17</span></a> Focussed cardiac assessment should only be performed in patients included in <a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>&#46; The some focussed cardiac assessment tests have been graded according to recommendation and level of evidence&#46; Cardiac risk should be combined with that of the surgery itself&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par1300" class="elsevierStylePara elsevierViewall">The use of risk indexes is widely debated&#46; Goldman&#39;s Index<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">1</span></a> was the first to gain prominence&#44; although it has been shown to have serious limitations&#46; The indexes developed by Detsky<a class="elsevierStyleCrossRef" href="#bib1425"><span class="elsevierStyleSup">86</span></a> and Lee<a class="elsevierStyleCrossRef" href="#bib1015"><span class="elsevierStyleSup">4</span></a> are the most widely used nowadays&#46; European guidelines<a class="elsevierStyleCrossRef" href="#bib1190"><span class="elsevierStyleSup">39</span></a> recommend Lee&#39;s index to stratify perioperative risk&#44; despite its obvious shortcomings&#44; including its inability to identify high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">54</span></a> Lee&#39;s index comprises six risk factors&#44; five of which depend on the patient&#39;s medical history&#58; history of ischaemic heart disease&#44; cerebrovascular disease&#44; heart failure&#44; insulin-dependent diabetes mellitus and kidney function impairment&#46; The sixth factor is high-risk surgery&#46; The Erasmus system performs better in terms of predicting and discriminating risk&#44; since it added age and a more detailed classification of surgical procedures to the equation&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">54</span></a></p><p id="par1305" class="elsevierStylePara elsevierViewall">Twelve-lead ECG is unreliable&#44; and many experts consider it redundant in patients with no cardiovascular risk factors&#46; Stress testing is included in what is called focussed cardiological assessment protocols &#40;<a class="elsevierStyleCrossRef" href="#tbl0045">Table 7</a>&#41;&#46; Stress testing should only be carried out in certain surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib1155"><span class="elsevierStyleSup">32</span></a></p><p id="par1310" class="elsevierStylePara elsevierViewall">Transthoracic echo &#40;TTE&#41; has become the gold standard preoperative evaluation&#59; it has few complications&#44; and gives a highly specific and sensitive diagnosis&#46; TTE should not be routinely performed&#44; although it should be included in focussed cardiological assessment protocols&#46; The benefit of TTE in patients with known&#44; but stable&#44; heart disease is unclear&#44;<a class="elsevierStyleCrossRefs" href="#bib1155"><span class="elsevierStyleSup">32&#44;39</span></a> and in this group of patients it should mainly be used to determine whether any clinical changes have occurred&#46; This &#8220;new&#8221; symptomatology that changes a patient&#39;s basal status is a definitive indication for TTE&#46; The &#8220;new&#8221; symptoms to be carefully evaluated are angina and signs of HF&#46;</p><p id="par1315" class="elsevierStylePara elsevierViewall">Holter monitoring&#44; myocardial perfusion scintigraphy and coronary angiography are rarely indicated in these patients&#44; and only as part of a focussed cardiological assessment&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;4&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0115">Cardiopulmonary exercise testing</span><p id="par1320" class="elsevierStylePara elsevierViewall">Cardiopulmonary exercise testing&#44; in which inhaled and exhaled gases are measured by means of a mask or nose prongs while the patient uses a static cycle or treadmill&#44; gives a more reliable measurement of cardiopulmonary function and oxygen uptake&#46; Cardiopulmonary exercise testing&#44; although not widely used&#44; helps stratify risk and optimise perioperative treatment in lung resection&#46;<a class="elsevierStyleCrossRefs" href="#bib1120"><span class="elsevierStyleSup">25&#44;87</span></a></p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0120">Risk limitation through chronic pharmacologic therapy for heart failure</span><p id="par1325" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0050"></elsevierMultimedia></p><p id="par1335" class="elsevierStylePara elsevierViewall">In these patients&#44; evaluation and optimisation targets vary according to functional status&#46; Patients with good functional status &#40;NYHA 1&#41; will not require diagnostic tests other than those included in standard preoperative evaluation protocols&#46;<a class="elsevierStyleCrossRef" href="#bib1190"><span class="elsevierStyleSup">39</span></a></p><p id="par1340" class="elsevierStylePara elsevierViewall">In patients with compensated HF &#40;NYHA I&#8211;II&#41; undergoing surgery with a risk factor of &#60;1&#37;&#44; medication should be maintained up to the day of the intervention&#46; Therapeutic measures should be optimised to try to improve the functional status of patients with symptoms of HF &#40;NYHA II&#8211;IV&#41;&#44; with a confirmed and evaluated diagnosis according to the algorithm shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; who require surgery with a &#60;1&#37; risk&#46;<a class="elsevierStyleCrossRefs" href="#bib1225"><span class="elsevierStyleSup">46&#44;48</span></a></p><p id="par1345" class="elsevierStylePara elsevierViewall">As a general rule&#44; the functional status of patients showing symptoms of HF with moderate exercise must be improved by adjusting their therapy&#46; Several studies have been published on the benefits of natriuretic peptide testing to determine the severity of HF versus clinical signs&#46; Although not supported by clear scientific evidence&#44; these studies suggest that NT-Pro BNP levels of &#62;2000<span class="elsevierStyleHsp" style=""></span>pg&#47;ml &#40;above all in patients<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>75 years&#41; predict a high risk of cardiac decompensation&#46;</p><p id="par1350" class="elsevierStylePara elsevierViewall">NT-Pro BNP levels &#60;400<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; meanwhile&#44; are associated with a low risk&#46;<a class="elsevierStyleCrossRefs" href="#bib1360"><span class="elsevierStyleSup">73&#44;88</span></a></p><p id="par1355" class="elsevierStylePara elsevierViewall">These results suggest that&#44; except in the most urgent surgery&#44; NT- Pro BNP levels should remain below 2000<span class="elsevierStyleHsp" style=""></span>pcg&#47;ml and as close as possible to 400<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; particularly in interventions with a risk rate of &#62;1&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a> shows the treatment schedule for CHF&#44; together with evidence for limiting risk using the usual medication given to these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1110"><span class="elsevierStyleSup">23&#44;30&#44;38&#44;48</span></a></p><p id="par1360" class="elsevierStylePara elsevierViewall">Perioperative administration of beta-blockers&#44; ACE inhibitors&#44; statins&#44; and aspirin significantly reduces intrahospital mortality in patients with depressed left ventricular function undergoing bypass surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">79</span></a> CHF treatment guidelines recommend administration of ACE inhibitors&#44; or angiotensin receptor blockers in case of intolerance&#44; with beta-blockers as first line treatment in HF to improve morbidity and mortality&#46; This treatment is important in HF patients&#44; and essential in patients with LVEF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#8211;45&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib1110"><span class="elsevierStyleSup">23&#44;48&#44;89</span></a></p><p id="par1365" class="elsevierStylePara elsevierViewall">Other drugs&#44; however&#44; can exacerbate the symptoms of HF or cause heart disturbances&#46; These include corticosteroids&#44; calcium-channel blockers&#44; class I and II antiarrhythmic agents&#44; minoxidil&#44; amphetamines&#44; dihydropyridines&#44; metformin&#44; anagrelide&#44; cilostazol&#44; carbamazepine&#44; clozapine&#44; ergot alkaloids&#44; pergolide&#44; tricyclic antidepressants&#44; B2 agonists&#44; itraconazole and infliximab&#46; Non-selective nonsteroidal anti-inflammatory drugs &#40;NSAIDS&#41; can worsen symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib1445"><span class="elsevierStyleSup">90</span></a></p><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0125">Beta-blockers</span><p id="par1370" class="elsevierStylePara elsevierViewall">Beta-blockers are perhaps the most effective drugs for reducing morbidity and mortality in HF patients&#46; Curiously&#44; few studies have been published on this subject&#46; The main aim of perioperative administration of beta-blockers is to reduce myocardial oxygen uptake by reducing heart rate&#46; This prolongs diastolic filling time and reduces contractility&#46;<a class="elsevierStyleCrossRef" href="#bib1450"><span class="elsevierStyleSup">91</span></a> Recent studies&#44; however&#44; have rekindled the old controversy over the use of beta-blockers in noncardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1455"><span class="elsevierStyleSup">92</span></a></p><p id="par1375" class="elsevierStylePara elsevierViewall">Preoperative suspension of beta-blockers in HF patients is not justified&#44; and if they have not previously been given but are indicated&#44; they should be started&#46; In the case of urgent surgery&#44; they should be administered intravenously immediately before surgery and continued in the postoperative period&#46; Mangano<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">3</span></a> published a study on the efficacy of beta-blockers in reducing long-term mortality&#44; and these findings were later confirmed by several other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib1385"><span class="elsevierStyleSup">78&#44;80&#44;93</span></a> Recently&#44; Andersson confirmed the prognostic value of beta-blockers in patients with ischaemic HF undergoing noncardiac surgery in a study in over 700&#44;000 patients&#46;<a class="elsevierStyleCrossRef" href="#bib1465"><span class="elsevierStyleSup">94</span></a></p><p id="par1380" class="elsevierStylePara elsevierViewall">Initially&#44; beta-blockers should be continued in patients already receiving this therapy&#46; They should be given to high-risk patients and patients with ischaemic heart disease at least one week before surgery&#46;</p><p id="par1385" class="elsevierStylePara elsevierViewall">In patients with decompensated HF&#44; beta-blockers can be down-dosed or temporarily suspended&#44;<a class="elsevierStyleCrossRef" href="#bib1110"><span class="elsevierStyleSup">23</span></a> and even surgery should be suspended until treatment has been optimised&#46; There are several contraindications for beta blockers&#44; the most important being&#58; asthma&#44; known hypersensitivity to the active ingredient&#44; sinus bradycardia&#44; cardiogenic shock&#44; hypotension&#44; metabolic acidosis&#44; serious peripheral artery disease&#44; second or third degree atrioventricular block&#44; sick sinus syndrome&#44; untreated phaeochromocytoma and manifest heart failure&#46; These contraindications should be borne in mind&#44; although beta-blockers are not contraindicated in intermittent claudication&#46;<a class="elsevierStyleCrossRefs" href="#bib1445"><span class="elsevierStyleSup">90&#8211;95</span></a></p><p id="par1390" class="elsevierStylePara elsevierViewall">When surgery can be delayed&#44; beta-blocker therapy should start from one week to one month before the intervention&#46; This rules out urgent&#44; non-delayable surgery&#46; Treatment should start with low-dose beta blockers&#44; which can then be adjusted in the period leading up to the intervention until the patient has a resting heart rate of 60&#8211;70<span class="elsevierStyleHsp" style=""></span>bpm&#44; and systolic pressure is higher than 00<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0130">Nitrates</span><p id="par1395" class="elsevierStylePara elsevierViewall">The effect of nitrates is well known&#44; but the benefits of routine use of these drugs is unclear&#46; Nitrates reduce perioperative myocardial ischaemia in patients with stable angina receiving intravenous nitroglycerine during noncardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1475"><span class="elsevierStyleSup">96&#44;97</span></a> Nitrates do not reduce mortality or prevent acute myocardial infarction&#46; Perioperative use of nitroglycerine can alter haemodynamic parameters&#44; since it can reduce preload and cause hypotension and tachycardia&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0135">Statins</span><p id="par1400" class="elsevierStylePara elsevierViewall">Systematic used of statins in surgical patients at cardiovascular risk is becoming increasingly important&#46; Patients with atherosclerosis should be given preoperative statins for secondary prevention&#44; independent of the type of surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib1085"><span class="elsevierStyleSup">18&#44;98&#44;99</span></a> since these agents have been shown to significantly reduce complications&#46;<a class="elsevierStyleCrossRefs" href="#bib1485"><span class="elsevierStyleSup">98&#8211;102</span></a></p><p id="par1405" class="elsevierStylePara elsevierViewall">Statins are equally beneficial&#44; irrespective of the pathogenesis of HF and cholesterol levels&#46;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">2</span></a></p><p id="par1410" class="elsevierStylePara elsevierViewall">They are not&#44; however&#44; entirely free from side effects&#44; and the risk of myopathy and rhabdomyolysis in surgical patients is of considerable concern&#44; above all in those with impaired kidney function&#46; If myopathy is not detected&#44; and statins are maintained&#44; there is a risk of rhabdomyolysis and acute kidney failure&#44;<a class="elsevierStyleCrossRef" href="#bib1500"><span class="elsevierStyleSup">101</span></a> however&#44; suspension of statins worsens the prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib1510"><span class="elsevierStyleSup">103</span></a> Administration of statins in surgical patients is hindered by the absence of an intravenous formulation of the drug&#46; This can be compensated in part with long half-life or slow-release statins&#44; such as extended-release rosuvastatin&#44; atorvastatin and fluvastatin&#44; which prolong the effect of the drug&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0140">Diuretics</span><p id="par1415" class="elsevierStylePara elsevierViewall">Diuretics can be used to control symptoms&#44; and should be given to HF patients with signs and symptoms of congestion&#46; In patients with difficult-to-control symptoms &#40;NYHA III or IV&#41; or LVEF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>35&#37;&#44; association with an aldosterone receptor antagonist should be considered&#46;</p><p id="par1420" class="elsevierStylePara elsevierViewall">There is no evidence to show that loop diuretics can affect mortality&#44; although potassium-sparing diuretics have been shown to be beneficial in this regard&#46; Loop diuretics such as furosemide and torasemide&#44; being more effective&#44; should be used in patients with advanced disease and also to treat exacerbations&#44; while thiazide diuretics such as chlorthalidone and hydrochlorothiazide should be given in less advanced stages&#46; Kidney function must always be considered when administering these drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib1225"><span class="elsevierStyleSup">46&#44;48</span></a></p><p id="par1425" class="elsevierStylePara elsevierViewall">Torasemide is associated with less urine output than furosemide&#44; and is an aldosterone antagonist&#46; Oral diuretics are poorly absorbed by patients with intestinal oedema&#44; and in these case they should be administered intravenously&#46; Thiazides are ineffective when creatinine clearance is less than 30&#37;&#44; and it is important to bear in mind their &#8220;therapeutic ceiling&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib1200"><span class="elsevierStyleSup">41</span></a></p><p id="par1430" class="elsevierStylePara elsevierViewall">They are frequently used in hypertensive or HF patients&#46; Electrolyte imbalance is common in patients receiving diuretics&#44; particularly hypokalaemia&#44; which increases the risk of tachycardia and ventricular fibrillation&#46;<a class="elsevierStyleCrossRef" href="#bib1515"><span class="elsevierStyleSup">104</span></a> Hypokalaemia increases perioperative mortality&#44;<a class="elsevierStyleCrossRef" href="#bib1520"><span class="elsevierStyleSup">105</span></a> and preoperative potassium and magnesium levels must always be determined&#46;</p><p id="par1435" class="elsevierStylePara elsevierViewall">Aldosterone antagonists&#44; spironolactone and eplerenone&#44; block the action of aldosterone receptors by increasing sodium and water excretion in urine and reducing potassium levels&#46; They should only be used in patients with good kidney function and normal serum potassium levels&#46; The beneficial effect of diuretics on cardiac remodelling&#44; myocardial fibrosis and regression of hypertrophy has earned them a place in long-term HF treatment strategies&#46; Several studies have found them to have a beneficial effect on survival&#46;<a class="elsevierStyleCrossRefs" href="#bib1050"><span class="elsevierStyleSup">11&#44;48&#44;106&#8211;108</span></a></p><p id="par1440" class="elsevierStylePara elsevierViewall">Preoperative up-dosing of diuretics can cause relative hypovolaemia&#44; which is often asymptomatic&#44; and far from being beneficial&#44; can even destabilise the patient&#46; Diuretics should be continued until the day of surgery&#44; and then restarted&#44; intravenously if needed&#44; as soon as possible&#46; Hypovolaemia and electrolyte disturbance are the main problems encountered in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib1530"><span class="elsevierStyleSup">107</span></a></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0145">Aspirin</span><p id="par1445" class="elsevierStylePara elsevierViewall">Aspirin is a common therapy in HF&#44; but few studies on the perioperative use of this drug have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib1545"><span class="elsevierStyleSup">110&#44;111</span></a></p><p id="par1450" class="elsevierStylePara elsevierViewall">The effects of aspirin on coagulation have been widely debated&#46; Aspirin should not be suspended to deliver locoregional anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib1555"><span class="elsevierStyleSup">112</span></a> Perioperative aspirin increases the risk of bleeding by 1&#46;5&#37;&#44; but does not cause any serious complications&#46;<a class="elsevierStyleCrossRef" href="#bib1560"><span class="elsevierStyleSup">113</span></a> The risk of serious cardiovascular complications following interruption of aspirin&#44; however&#44; is three times higher&#46;<a class="elsevierStyleCrossRef" href="#bib1565"><span class="elsevierStyleSup">114</span></a> Aspirin should not&#44; a priori&#44; be suspended for minor surgery or endoscopy&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;6</span><span class="elsevierStyleSectionTitle" id="sect0150">Anticoagulants</span><p id="par1455" class="elsevierStylePara elsevierViewall">Comorbidity is extremely common in HF patients&#44; and they are at risk for thromboembolic complications&#46; Anticoagulation with coumarin derivatives should be maintained in all HF and chronic or paroxysmal atrial fibrillation patients&#46; Anticoagulants should be given to patients presenting significant ventricular dilation&#44; ventricular aneurysm&#44; or LVEF less than 20&#37; in sinus rhythm&#46; Anticoagulants are associated with increased bleeding during noncardiac surgery&#46; In some procedures&#44; such as cataract surgery&#44; the benefits of anticoagulation therapy outweigh the risk of haemorrhage&#44; and should be continued&#46;</p><p id="par1460" class="elsevierStylePara elsevierViewall">Patients receiving oral anticoagulation with vitamin K antagonists are at greater risk for peri- and postoperative bleeding&#46; Surgery can safely be performed&#44; provided INR is &#60;1&#46;5&#46; In this case&#44; however&#44; due to the risk of thrombosis&#44; bridge therapy with low-molecular-weight heparins should be given in accordance with well-established protocols&#46;<a class="elsevierStyleCrossRef" href="#bib1570"><span class="elsevierStyleSup">115</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;7</span><span class="elsevierStyleSectionTitle" id="sect0155">Angiotensin-converting enzyme inhibitors &#40;ACE inhibitors&#41; and angiotensin receptor blockers &#40;ARBs&#41;</span><p id="par1465" class="elsevierStylePara elsevierViewall">ACE inhibitors are indicated in any functional class of systolic HF &#40;LVEF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41;&#44; in the absence of contraindications or intolerance&#46; They have been shown to delay evolution of the disease&#44; improve symptoms&#44; and reduce mortality&#46; The secondary effects of ACE inhibitors include kidney failure&#44; hypokalaemia&#44; symptomatic hypotension&#44; unproductive cough in up to 10&#8211;15&#37; of patients&#44; and even angiooedema&#46;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">30&#44;38</span></a></p><p id="par1470" class="elsevierStylePara elsevierViewall">Their endothelial and anti-inflammatory action protects against organ damage&#44; which could be beneficial in the postoperative period&#46;<a class="elsevierStyleCrossRefs" href="#bib1575"><span class="elsevierStyleSup">116&#44;117</span></a> Therefore&#44; they should be continued&#44; despite concerns initially raised about their effect on kidney function&#46;<a class="elsevierStyleCrossRef" href="#bib1585"><span class="elsevierStyleSup">118</span></a> They do&#44; however&#44; cause severe hypotension during anaesthesia&#44; particularly in patients taking beta-blockers&#46; Hypotension is less severe if ACE inhibitors are interrupted 24<span class="elsevierStyleHsp" style=""></span>h before surgery&#44; although this indication is still under discussion&#46; Hypotension is more severe and difficult to control in patients taking ARBs&#46;<a class="elsevierStyleCrossRef" href="#bib1540"><span class="elsevierStyleSup">109</span></a></p><p id="par1475" class="elsevierStylePara elsevierViewall">ARBs are indicated in systolic HF when ACE inhibitors are poorly tolerated&#44; or in patients with persistent symptoms refractory to ACE inhibitors and a beta-blocker&#46; They have been shown to be equally beneficial as ACE inhibitors in reducing the risk of mortality&#46; They should not be given to patients taking combination ACE inhibitor plus aldosterone receptor antagonist&#46;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">30&#44;38&#44;119</span></a></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;8</span><span class="elsevierStyleSectionTitle" id="sect0160">Calcium channel blockers</span><p id="par1480" class="elsevierStylePara elsevierViewall">Calcium channel blockers can be used to reduce risk&#44; however&#44; it is important to distinguish between dihydropyridines&#44; which do not directly affects heart rate&#44; and diltiazem or verapamil&#44; which decrease heart rate&#46; Although evidence is scant&#44; an analysis of the literature shows that they reduce ischaemia and supraventricular tachycardia&#46;<a class="elsevierStyleCrossRefs" href="#bib1595"><span class="elsevierStyleSup">120&#44;121</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;9</span><span class="elsevierStyleSectionTitle" id="sect0165">Alpha-2 agonists</span><p id="par1485" class="elsevierStylePara elsevierViewall">Alpha-2 agonists can reduce intraoperative catecholamine release&#46; Although there is no conclusive evidence that they reduce mortality or myocardial infarction in HF patients undergoing intermediate or high risk surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib1605"><span class="elsevierStyleSup">122&#44;123</span></a> they have been shown to reduce morbidity and mortality in the vascular surgery subgroup&#46; Some more recent studies have reported that perioperative clonidine is effective in reducing mortality&#46;<a class="elsevierStyleCrossRef" href="#bib1615"><span class="elsevierStyleSup">124</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;5&#46;10</span><span class="elsevierStyleSectionTitle" id="sect0170">Pharmacological management of diastolic heart failure</span><p id="par1490" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0030">Table 4</a> shows the treatment schedule for diastolic HF&#46;<a class="elsevierStyleCrossRefs" href="#bib1060"><span class="elsevierStyleSup">13&#44;30&#44;34&#44;46&#44;48</span></a> As yet&#44; no treatment has been shown conclusively to reduce morbidity and mortality in HF patients with preserved LVEF&#46; Diuretics are used to control sodium and water retention and reduce dyspnoea and oedema&#44; as in HF with depressed LVEF&#46; In patients with AF&#44; it is important to control myocardial ischaemia&#44; hypertension and heart rate&#46; Remember&#44; calcium channel blockers can improve symptoms and exercise capacity in these patients&#44; but they are not recommended in patients with ventricular dysfunction due to their negative inotropic effect&#46; Beta-blockers can also be used to control heart rate in patients in AF and in patients with HF with preserved LVEF&#46;<a class="elsevierStyleCrossRefs" href="#bib1030"><span class="elsevierStyleSup">7&#44;48&#44;64</span></a> The same drugs advised against in systolic HF are also discouraged in diastolic HF&#44; with the exception of calcium channel blockers&#46;</p></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;6</span><span class="elsevierStyleSectionTitle" id="sect0175">Preoperative revascularisation as a risk reduction strategy</span><p id="par1495" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0055"></elsevierMultimedia></p><p id="par1505" class="elsevierStylePara elsevierViewall">Preoperative bypass prevents acute myocardial infarction&#46; However&#44; although it is extremely effective in severe stenosis&#44; it cannot prevent plaque rupture caused by the stress response to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1205"><span class="elsevierStyleSup">42</span></a></p><p id="par1510" class="elsevierStylePara elsevierViewall">Stable patients can safely undergo noncardiac surgery five years after bypass surgery&#44; irrespective of their LVEF&#46;<a class="elsevierStyleCrossRef" href="#bib1620"><span class="elsevierStyleSup">125</span></a></p><p id="par1515" class="elsevierStylePara elsevierViewall">In patients with stents&#44; mortality due to acute intraoperative thrombosis of the stent is as high as 20&#37; when surgery is performed a few weeks after implantation and antiplatelet therapy has been suspended&#46; This is why elective surgery should be postponed for at least 6 weeks or up to 3 months&#44; if possible&#44; following implantation of bare metal stents&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#46;<a class="elsevierStyleCrossRef" href="#bib1625"><span class="elsevierStyleSup">126</span></a> After this time&#44; surgery can be performed if aspirin is maintained&#46;<a class="elsevierStyleCrossRef" href="#bib1630"><span class="elsevierStyleSup">127</span></a></p><p id="par1520" class="elsevierStylePara elsevierViewall">The situation is very different with drug-eluting stents &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; since aspirin and clopidogrel must be continued for at least 12 months&#46; If&#44; during this interval&#44; the patient requires surgery and antiplatelet treatment is suspended&#44; the risk of complications increases&#46;<a class="elsevierStyleCrossRef" href="#bib1635"><span class="elsevierStyleSup">128</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par1525" class="elsevierStylePara elsevierViewall">Very little information is available on the use of prophylactic revascularisation in patients with stable ischaemic heart disease&#46; The &#8220;Coronary Artery Revascularization Prophylaxis &#40;CARP&#41;&#8221; study found that revascularisation prior to vascular surgery had no discernible effect&#46; Initially&#44; no differences were observed in long-term mortality at 2&#46;7 years following inclusion in the study&#46;<a class="elsevierStyleCrossRef" href="#bib1640"><span class="elsevierStyleSup">129</span></a> However&#44; the inclusion criteria for this study are controversial&#44; and the study population was relatively low-risk&#46;</p><p id="par1530" class="elsevierStylePara elsevierViewall">The benefit of revascularisation in patients with stable ischaemic heart disease scheduled for surgery remains unclear&#44; and recommendations are associated with a low level of evidence&#46; Revascularisation is a reasonable strategy&#44; although bypass surgery is needed in significant left main artery disease and triple vessel disease&#44; particular with LVEF involvement&#46; Percutaneous coronary intervention should be performed in symptomatic&#44; stable&#44; single- or double-vessel disease&#46;<a class="elsevierStyleCrossRefs" href="#bib1645"><span class="elsevierStyleSup">130&#44;131</span></a></p><p id="par1535" class="elsevierStylePara elsevierViewall">Prophylactic revascularisation in patients with unstable ischaemic heart disease scheduled for noncardiac surgery has not been investigated&#46; Unstable angina and non-ST elevation ACS are high risk situations that require revascularisation&#46;<a class="elsevierStyleCrossRef" href="#bib1655"><span class="elsevierStyleSup">132</span></a> In patients with unstable angina scheduled for urgent surgery &#40;cancer surgery&#44; etc&#46;&#41;&#44; particular care should be taken to avoid intensive use of anticoagulants and&#47;or antiplatelet therapy due to the increased risk of secondary haemorrhage&#46;</p><p id="par1540" class="elsevierStylePara elsevierViewall">In patients with unstable angina scheduled for non-urgent noncardiac surgery&#44; bare metal stents should be implanted to avoid delaying the intervention by more than 3 months&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;7</span><span class="elsevierStyleSectionTitle" id="sect0180">Perioperative arrhythmia in heart failure patients undergoing noncardiac surgery</span><p id="par1545" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0060"></elsevierMultimedia></p><p id="par1555" class="elsevierStylePara elsevierViewall">Arrhythmias are common in HF patients undergoing general anaesthesia&#46;<a class="elsevierStyleCrossRefs" href="#bib1660"><span class="elsevierStyleSup">133&#44;134</span></a> Tachycardia is a serious&#44; complex problem that worsens ischaemia and compromises haemodynamic stability by shortening diastolic filling time and preventing full ventricular filling&#46; Tachycardia in HF patients can have serious consequences&#44;</p><p id="par1560" class="elsevierStylePara elsevierViewall">Tachycardia can also significantly compromise the evolution of coronary patients&#44; or patients with either systolic or diastolic HF&#46; Aggressive treatment is needed to address tachycardia&#44; once anaemia&#44; hypovolaemia&#44; pain&#44; and catecholamine overdose have been ruled out&#46; Short-acting beta-blockers such as esmolol are first line therapy in tachycardia&#44; particularly in coronary patients&#46;</p><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;7&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0185">Ventricular arrhythmia</span><p id="par1565" class="elsevierStylePara elsevierViewall">Although ventricular premature beats are common&#44; they are not associated with poorer prognosis&#46; Sustained monomorphic ventricular tachycardia with serious haemodynamic compromise must be treated promptly with electric cardioversion&#46;<a class="elsevierStyleCrossRef" href="#bib1245"><span class="elsevierStyleSup">50</span></a> Initially&#44; intravenous amiodarone should be given&#46;</p><p id="par1570" class="elsevierStylePara elsevierViewall">Patients with sustained polymorphic ventricular tachycardia and haemodynamic deterioration must be treated promptly with electric cardioversion&#46; Beta-blockers are useful in these patients if ischaemia is suspected&#46; Amiodarone is also a reasonable therapeutic option in the absence of long QT syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib1245"><span class="elsevierStyleSup">50</span></a><span class="elsevierStyleItalic">Torsades de Pointes</span> rarely occurs&#46; If it does&#44; it should be treated with magnesium sulphate&#44; and when triggered by sinus bradycardia&#44; pacing and suspension of beta-blockers is recommended&#46; Isoproterenol is recommended in patients with recurrent pause-dependent <span class="elsevierStyleItalic">Torsades de Pointes</span> who do not have congenital long QT syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib1245"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;7&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0190">Supraventricular arrhythmia</span><p id="par1575" class="elsevierStylePara elsevierViewall">Supraventricular arrhythmias are far more prevalent&#46;<a class="elsevierStyleCrossRefs" href="#bib1245"><span class="elsevierStyleSup">50&#44;135</span></a> The main trigger mechanism of these arrhythmias is sympathetic activity&#46;<a class="elsevierStyleCrossRef" href="#bib1665"><span class="elsevierStyleSup">134</span></a> Vagal manoeuvres may terminate supraventricular arrhythmias in some cases&#46; These arrhythmias respond well to treatment with adenosine&#44; but when this fails&#44; esmolol or a non-dihydropyridine calcium channel blocker &#40;diltiazem and verapamil&#41; or IV amiodarone should be given&#46;<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">16</span></a></p><p id="par1580" class="elsevierStylePara elsevierViewall">AF is undoubtedly the most common form of arrhythmia&#46; Amiodarone or diltiazem are important in chronic or new onset AF with rapid ventricular response&#46; If beta-blockers have been ruled out&#44; and AF is new onset&#44; the treatment of choice should be electric defibrillation&#46;<a class="elsevierStyleCrossRefs" href="#bib1220"><span class="elsevierStyleSup">45&#44;136</span></a> Digitalis and similar drugs should only be first-line therapy in patients with chronic HF&#44; since they are not effective in high adrenergic states such as surgery&#46; Beta-blockers have been shown to accelerate the conversion of AF to sinus rhythm after noncardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1680"><span class="elsevierStyleSup">137</span></a></p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4&#46;7&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0195">Implantable devices and surgery</span><p id="par1585" class="elsevierStylePara elsevierViewall">Electrocautery is dangerous in pacemaker-dependent patients&#44; as the electrical stimulus from the device interferes with the pacemaker&#46; The problem can be avoided by placing the ground plate for the electric circuit in such a way that the electrical current travels away from the generator&#46; Keeping the electrocautery device away from the pacemaker&#44; giving only brief bursts and using the lowest possible amplitude may decrease the interference&#46;</p><p id="par1590" class="elsevierStylePara elsevierViewall">Some authors recommend setting the pacemaker in asynchronous or non-sensing mode in pacemaker-dependent patients&#44; and reprogramming after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1685"><span class="elsevierStyleSup">138</span></a></p><p id="par1595" class="elsevierStylePara elsevierViewall">Similar interference can also occur with implantable cardioverter defibrillators during surgery&#46; They should be deactivated during the intervention and reactivated in the recovery room prior to transferring the patient to the ward&#46;<a class="elsevierStyleCrossRef" href="#bib1690"><span class="elsevierStyleSup">139</span></a></p></span></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="sect0200">Intraoperative risk reduction in HF patients scheduled for noncardiac surgery</span><p id="par1600" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0065"></elsevierMultimedia></p><p id="par1610" class="elsevierStylePara elsevierViewall">This section deals with limiting risks perioperatively and in the immediate preoperative period&#46; The concept of risk reduction<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">37</span></a> is based on a broad view of the patient as a whole before&#44; during and after the intervention&#46; When applied to heart surgery&#44; risk reduction could be defined as preservation of intraoperative cardiac function at all times&#44; particularly during surgery&#44; irrespective of the patient&#39;s situation&#44; in the knowledge that the task will become more difficult as myocardial function worsens&#46; It is important to bear in mind that the worse the preoperative functional status&#44; the greater the perioperative deterioration&#46;</p><p id="par1615" class="elsevierStylePara elsevierViewall">This simple concept reveals the fundamental need to make every effort to optimise patients with compromised heart function&#44; i&#46;e&#46;&#44; depressed LVEF&#59; optimisation and cardioprotection are the key words&#46;</p><p id="par1620" class="elsevierStylePara elsevierViewall">Clinicians are well aware of the importance of monitoring and anaesthetic technique&#44; despite scarce evidence in the literature&#44; while preconditioning and haemodynamic optimisation are new strategies that can play a fundamental role in reducing risk in HF patients&#46;</p><p id="par1625" class="elsevierStylePara elsevierViewall">Goal-directed haemodynamic optimisation therapy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; is of the utmost importance in HF patients&#46; It is important to stress that optimisation is only possible with good monitoring &#40;<a class="elsevierStyleCrossRef" href="#tbl0050">Table 8</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">17&#44;140</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0050"></elsevierMultimedia><p id="par1630" class="elsevierStylePara elsevierViewall">Conditioning can be defined as the process of stimulating biological mechanisms capable of limiting the structural or functional damage caused by an injury&#46; Conditioning can be achieved by drugs or ischaemic manoeuvres&#46; If the drug or manoeuvres are effective before the injury occurs&#44; it is called preconditioning&#46; If it is effective while the injury occurs&#44; it is called conditioning&#59; and if it is effective after the injury occurs&#44; it is called postconditioning&#46; In all three strategies&#44; the mechanism remains the same&#59; only the point at which the drug is administered or the ischaemic manoeuvre performed differs&#46;<a class="elsevierStyleCrossRefs" href="#bib1700"><span class="elsevierStyleSup">141&#8211;148</span></a></p><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0205">Haemodynamic monitoring</span><p id="par1635" class="elsevierStylePara elsevierViewall">Basic monitoring techniques required in all anaesthetic procedures might not be sufficient in more high-risk patients&#44; although there is little evidence to corroborate this&#46;<a class="elsevierStyleCrossRef" href="#bib1740"><span class="elsevierStyleSup">149</span></a> Central venous pressure and invasive arterial pressure monitoring&#44; though useful&#44; are insufficient&#46;<a class="elsevierStyleCrossRefs" href="#bib1745"><span class="elsevierStyleSup">150&#8211;152</span></a> In HF patients&#44; therefore&#44; advanced haemodynamic monitoring is based on parameters that can facilitate perioperative haemodynamic optimisation &#40;<a class="elsevierStyleCrossRef" href="#tbl0050">Table 8</a>&#41;&#46; The techniques usually used are central venous oxygen saturation &#40;ScvO<span class="elsevierStyleInf">2</span>&#41;<a class="elsevierStyleCrossRef" href="#bib1760"><span class="elsevierStyleSup">153</span></a> pulmonary artery catheter &#40;Swan Ganz&#41;&#44; including continuous thermodilution cardiac output monitoring &#40;CCO&#41; and mixed oxygen saturation &#40;SvO<span class="elsevierStyleInf">2</span>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib1765"><span class="elsevierStyleSup">154&#8211;157</span></a> pulse wave analysis systems&#44; including transpulmonary thermodilution &#40;PiCCO&#41;&#44; lithium dilution &#40;LIDCO&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib1785"><span class="elsevierStyleSup">158&#44;159</span></a> partial carbon-dioxide &#40;CO<span class="elsevierStyleInf">2</span>&#41; rebreathing&#44;<a class="elsevierStyleCrossRef" href="#bib1795"><span class="elsevierStyleSup">160</span></a> transthoracic electrical bioimpedence<a class="elsevierStyleCrossRefs" href="#bib1800"><span class="elsevierStyleSup">161&#8211;163</span></a> and ultrasound monitoring techniques&#44; including transesophageal Doppler<a class="elsevierStyleCrossRefs" href="#bib1815"><span class="elsevierStyleSup">164&#44;165</span></a> or echocardiography&#46;<a class="elsevierStyleCrossRefs" href="#bib1190"><span class="elsevierStyleSup">39&#44;166&#8211;168</span></a></p><p id="par1640" class="elsevierStylePara elsevierViewall">Pulmonary artery catheters are not usually indicated due to the characteristics of HF patients&#46; Some studies report no benefits in the use of this technique&#44;<a class="elsevierStyleCrossRefs" href="#bib1840"><span class="elsevierStyleSup">169&#44;170</span></a> and no differences in mortality and length of hospital stay&#44; although patients with pulmonary artery catheter were more prone to pulmonary embolism&#46;</p><p id="par1645" class="elsevierStylePara elsevierViewall">The choice of monitoring technique depends on a wide range of factors that are outside the scope of this guideline&#46; However&#44; the choice of parameter or parameters measured will be essential to guide therapeutic decisions aimed at minimising the consequences of surgical aggression&#46; In all monitoring techniques&#44; it is important to evaluate any possible complications arising from their use&#44; and the level of evidence assigned to their indication&#46;</p><p id="par1650" class="elsevierStylePara elsevierViewall">However&#44; monitoring options are sometimes limited by the resources available&#46; If advanced haemodynamic monitors are not available&#44; a variation of more than 10&#37; in systolic blood pressure between inhalation and exhalation &#40;minimum tidal volume of 8&#8211;10<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#44; shown on an arterial pulse wave&#44; can give an indication of volume response in a hypotensive patient&#46; Variations in plethysmographic waveform can also be used&#46; An increase of more than 5&#37; in arterial pressure 15<span class="elsevierStyleHsp" style=""></span>s after interrupting mechanical ventilation at the end of expiration can predict preload responsiveness&#46;<a class="elsevierStyleCrossRef" href="#bib1755"><span class="elsevierStyleSup">152</span></a> If the circumstances call for the use of inotropes&#44; once haemoglobin and afterload have been optimised central venous saturation can be measured from time to time with a central catheter&#46; This will show whether oxygen delivery and consumption are balanced&#46;</p><p id="par1655" class="elsevierStylePara elsevierViewall">In conclusion&#44; obtaining useful measurements is the key to monitoring HF patients&#46; The data obtained must be rapidly and reliably updated with the least possible calibration&#46; Monitoring must be adapted to goals&#44; haemodynamic optimisation&#44; the patient&#39;s risk&#44; the type of surgery&#44; and the likelihood of complications&#46;</p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0210">Haemodynamic optimisation</span><p id="par1660" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0070"></elsevierMultimedia></p><p id="par1670" class="elsevierStylePara elsevierViewall">Goal-directed haemodynamic optimisation therapy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; is a powerful therapeutic strategy that should be used whenever required&#44; although it is usually used in the hours leading up to surgery&#44; during the intervention&#44; and in the first few hours post-surgery&#46;</p><p id="par1675" class="elsevierStylePara elsevierViewall">There is ample evidence that high-risk surgical patients treated according to goal-directed haemodynamic optimisation in the perioperative period are at less risk of mortality and morbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib1850"><span class="elsevierStyleSup">171&#44;172</span></a> Haemodynamic optimisation is based on oxygen delivery to tissues &#40;DO<span class="elsevierStyleInf">2</span>&#41;&#46; Although monitoring techniques have changed&#44; therapeutic tools remain the same&#58; intravenous solutions &#40;crystalloids&#44; colloids and haemoderivatives&#41;&#44; vasoactive drugs &#40;vasopressors&#44; inotropes&#44; vasodilators&#41; and oxygen&#46;</p><p id="par1680" class="elsevierStylePara elsevierViewall">The aim of haemodynamic optimisation is to maintain DO<span class="elsevierStyleInf">2</span> above critical levels&#46;<a class="elsevierStyleCrossRef" href="#bib1860"><span class="elsevierStyleSup">173</span></a> Mixed venous saturation &#40;SvO<span class="elsevierStyleInf">2</span>&#41; and central venous saturation &#40;ScO<span class="elsevierStyleInf">2</span>&#41; levels are extremely important&#46;</p><p id="par1685" class="elsevierStylePara elsevierViewall">DO<span class="elsevierStyleInf">2</span> cannot be improved without first improving cardiac output &#40;CO&#41; and blood oxygen levels &#40;CaO<span class="elsevierStyleInf">2</span>&#41;&#46; CaO<span class="elsevierStyleInf">2</span> depends on the haematocrit and SpO<span class="elsevierStyleInf">2</span>&#44; preload cardiac output&#44; afterload&#44; heart rate&#44; and LV compliance&#44; in the absence of VD&#46;<a class="elsevierStyleCrossRef" href="#bib1860"><span class="elsevierStyleSup">173</span></a></p><p id="par1690" class="elsevierStylePara elsevierViewall">Haemodynamic optimisation requires optimisation of myocardial contractility&#44; preload&#44; afterload&#44; heart rhythm and heart rate&#44; particularly if the patient is in AF&#44; correction of anaemia and adequate gas exchange&#46; In terms of haemodynamics&#44; liquids to increase systolic volume &#40;SV&#41; can only be given in patients with adequate heart function&#46; For this reason&#44; concomitant inotropes are essential in patients with LVEF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The most widely studied parameters have been systolic volume&#44; cardiac index &#40;CI&#41;&#44; mixed or central venous saturation &#40;SVO<span class="elsevierStyleInf">2</span>&#41; and oxygen delivery &#40;DO<span class="elsevierStyleInf">2</span>&#41;&#46; Studies have shown that this strategy improves outcomes&#46;</p><p id="par1695" class="elsevierStylePara elsevierViewall">In practical terms&#44; cardiac output must be optimised without causing fluid overload&#44; which can be extremely harmful to these patients&#46; Estimating cardiac preload using dynamic indices can give early indication of the need for inotropes&#46; In unstable or high-risk patients&#44; preoperative haemodynamic optimisation is usually achieved with catecholamines&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46; This strategy has been shown to be extremely effective&#46;<a class="elsevierStyleCrossRefs" href="#bib1850"><span class="elsevierStyleSup">171&#44;174</span></a></p><p id="par1700" class="elsevierStylePara elsevierViewall">If the myocardium is unresponsive to preload&#44; cardiac function must be increased pharmacologically and the cause of the dysfunction analysed without delay&#58; anaemia&#44; low diastolic pressure&#44; ischaemic event or acute mechanical complication&#46; This means that at times inotropic support can be started&#44; and then withdrawn with haemoglobin delivery&#44; or afterload can be adjusted to ensure filling&#46; Automated intraoperative ST segment monitoring with lead combinations can warn of ischaemic events&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">17</span></a></p><p id="par1705" class="elsevierStylePara elsevierViewall">Despite their effectiveness&#44; catecholamines have some important side effects&#44; mainly increased myocardial oxygen consumption&#46; Some studies have reported that catecholamine and phosphodiesterase inhibitors increase mortality in HF patients&#44;<a class="elsevierStyleCrossRefs" href="#bib1870"><span class="elsevierStyleSup">175&#8211;178</span></a> although these findings are not echoed by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">33&#44;47&#44;179&#8211;182</span></a> It is important to note that this increase in mortality is based on data from medical patients&#44; and should never be extrapolated to surgical patients&#44; in whom catecholamines and phosphodiesterase inhibitors are essential&#46; These drugs&#44; however&#44; can in some cases be successfully replaced by levosimendan&#44; with even better results&#46;<a class="elsevierStyleCrossRef" href="#bib1910"><span class="elsevierStyleSup">183</span></a></p><p id="par1710" class="elsevierStylePara elsevierViewall">Levosimendan&#44; which increases cardiac contractility and vasodilation&#44; is a promising new drug&#46; Goal-directed therapy &#40;GDT&#41;&#44; therefore&#44; should ideally start between 12 and 24<span class="elsevierStyleHsp" style=""></span>h prior to surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1180"><span class="elsevierStyleSup">37&#44;82&#44;184&#8211;187</span></a></p><p id="par1715" class="elsevierStylePara elsevierViewall">The technique may cause some organisational disruptions&#44; since it requires patients to be transferred to the intensive care unit for continuous monitoring&#46; There is evidence to suggest that perfusion of 0&#46;05&#8211;0&#46;2<span class="elsevierStyleHsp" style=""></span>mc&#47;kg&#47;min levosimendan for a total dose of 12&#46;5<span class="elsevierStyleHsp" style=""></span>mg prior to surgery&#44; without a loading dose&#44; improves postoperative haemodynamic status and cardiorespiratory symptoms in HF patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1030"><span class="elsevierStyleSup">7&#44;82&#44;184&#44;185&#44;187</span></a></p><p id="par1720" class="elsevierStylePara elsevierViewall">Studies in ischaemia-reperfusion injury have shown patients with inadequate haemodynamic optimisation and&#47;or organ protection can be at risk for serious organic complications post-surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1935"><span class="elsevierStyleSup">188&#8211;190</span></a></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0215">Conditioning and its role in risk reduction</span><p id="par1725" class="elsevierStylePara elsevierViewall">Preconditioning&#44; the best-known stage of conditioning&#44; can be defined as the biological situation in which cellular protection mechanisms are activated as a result of a brief&#44; controlled ischaemic injury&#46;<a class="elsevierStyleCrossRef" href="#bib1700"><span class="elsevierStyleSup">141</span></a> Ischaemic conditioning produces an early and then a delayed mitochondrial protection response&#44; with less cellular apoptosis and less immune cell recruitment in the context of a systemic inflammatory response syndrome&#46; It also activates anti-ischaemia&#44; antiarrhythmic&#44; antistunning&#44; antiplatelet mechanisms&#44; and maintains endothelial function&#46; These mechanisms are not only triggered by controlled ischaemia-reperfusion injury&#44; but also pharmacologically&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib1945"><span class="elsevierStyleSup">190&#44;191</span></a></p><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0220">Remote ischaemic conditioning</span><p id="par1730" class="elsevierStylePara elsevierViewall">The concept of remote ischaemic conditioning was developed after observing the same protective effects in organs distant from the organ receiving the partial ischaemia&#46; Although it is not widely used in clinical practice&#44; it is part of the development of conditioning techniques&#46;</p><p id="par1735" class="elsevierStylePara elsevierViewall">Studies in humans are showing the advantages of this technique&#46;<a class="elsevierStyleCrossRefs" href="#bib1945"><span class="elsevierStyleSup">190&#8211;194</span></a> One such study in a series of paediatric patients treated for congenital heart defects has shown that four&#44; 5-min cycles of lower limb ischaemia reduced postoperative cardiac enzyme levels together with the need for inotropes and time on mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib1955"><span class="elsevierStyleSup">192</span></a> Salmenper&#228;&#44; in a randomised clinical trial in 82 patients undergoing elective abdominal aortic aneurysm repair&#44; showed a decrease in postoperative myocardial ischaemia events and kidney injury following intermittent crossclamping of the common iliac artery to induce 10-min ischaemia before aortic crossclamping&#44;<a class="elsevierStyleCrossRef" href="#bib1960"><span class="elsevierStyleSup">193</span></a> while a study in 225 patients undergoing percutaneous coronary intervention showed that repeated intermittent inflations of an intracoronary balloon reduced the risk of kidney complications&#46;<a class="elsevierStyleCrossRef" href="#bib1965"><span class="elsevierStyleSup">194</span></a> Not all authors&#44; however&#44; find remote ischaemic conditioning to be beneficial in cardiac interventions&#46;<a class="elsevierStyleCrossRef" href="#bib1725"><span class="elsevierStyleSup">146</span></a></p><p id="par1740" class="elsevierStylePara elsevierViewall">The biological mechanism of conditioning and preconditioning is extremely complex&#46; Ischaemia shuts off ATP production and triggers the release of adenosine&#44; which in turn activates mitochondrial ATP-sensitive K channels&#44; causing vasodilation and reducing the amount of Ca entering the cell&#46;<a class="elsevierStyleCrossRefs" href="#bib1970"><span class="elsevierStyleSup">195&#44;196</span></a></p><p id="par1745" class="elsevierStylePara elsevierViewall">There are a number of molecules capable of producing preconditioning or conditioning&#46; P2Y12 receptor antagonists&#44;<a class="elsevierStyleCrossRef" href="#bib1980"><span class="elsevierStyleSup">197</span></a> magnesium&#44; nicorandil and pinacidil all activate mitochondrial ATP-sensitive K channels&#44;<a class="elsevierStyleCrossRefs" href="#bib1985"><span class="elsevierStyleSup">198&#44;199</span></a> as do delta and kappa opioid agonists&#44;<a class="elsevierStyleCrossRef" href="#bib1705"><span class="elsevierStyleSup">142</span></a> volatile anaesthetics&#44;<a class="elsevierStyleCrossRef" href="#bib1995"><span class="elsevierStyleSup">200</span></a> propofol<a class="elsevierStyleCrossRef" href="#bib2000"><span class="elsevierStyleSup">201</span></a> and calcium sensitisers&#44; namely&#44; levosimendan&#46;<a class="elsevierStyleCrossRefs" href="#bib1405"><span class="elsevierStyleSup">82&#44;184&#44;185&#44;202&#8211;206</span></a></p><p id="par1750" class="elsevierStylePara elsevierViewall">The action of propofol is more widely debated&#46; Some studies report its protective effect&#44;<a class="elsevierStyleCrossRef" href="#bib2000"><span class="elsevierStyleSup">201</span></a> while others describe it as an inhibitor of ischaemic preconditioning&#46;<a class="elsevierStyleCrossRefs" href="#bib2030"><span class="elsevierStyleSup">207&#44;208</span></a></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0225">Pharmacological conditioning</span><p id="par1755" class="elsevierStylePara elsevierViewall">Tissue conditioning can also be achieved pharmacologically&#46; In the context of cardiac conditioning&#44; halogenated volatile anaesthetics and levosimendan are of particular interest&#46;<a class="elsevierStyleCrossRefs" href="#bib1700"><span class="elsevierStyleSup">141&#44;188&#8211;191</span></a> Other anaesthetics&#44; namely opioids and propofol&#44; have also been described as cardiac conditioning agents&#44; but far more evidence has been gathered on the use of halogenated volatile anaesthetics in this context&#46;</p><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3&#46;2&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0230">Halogenated volatile anaesthetics and conditioning</span><p id="par1760" class="elsevierStylePara elsevierViewall">Several authors<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">17&#44;209</span></a> recommend the use of volatile anaesthetics in certain specific situations&#44; such as myocardial ischaemia&#46; Volatile anaesthetics &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41; have been shown to be effective as conditioning and cell protection agents&#46;<a class="elsevierStyleCrossRefs" href="#bib1735"><span class="elsevierStyleSup">148&#44;210&#8211;212</span></a> Nonetheless&#44; some authors report widely differing clinical data that seems to contradict the general view&#46;<a class="elsevierStyleCrossRef" href="#bib2060"><span class="elsevierStyleSup">213</span></a> In the study in question&#44; however&#44; the dose of opioids and other drugs administered is not clear&#46; As this was left to the discretion of the anaesthesiologist&#44; it could constitute a bias that could skew the results of the study&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par1765" class="elsevierStylePara elsevierViewall">Using sevofluorane in the anaesthesia delivered to a deceased-donor liver transplant recipient reduced the incidence of early allograft dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib1730"><span class="elsevierStyleSup">147</span></a> The findings of a retrospective review of liver surgery in several Spanish hospitals also found benefits in the use of volatile anaesthetics&#44; although due to the heterogeneity of the groups studies&#44; no statistical significance was found&#46;<a class="elsevierStyleCrossRef" href="#bib2065"><span class="elsevierStyleSup">214</span></a> In these studies&#44; the use of propofol in the control group did not show the same benefits&#44; showing that it does not have a clinically relevant conditioning effect&#46;</p><p id="par1770" class="elsevierStylePara elsevierViewall">In another study&#44; bronchoalveolar lavage samples showed less alveolar inflammation in the single ventilated lung of subjects receiving volatile anaesthetics during thoracic surgery&#46;<a class="elsevierStyleCrossRef" href="#bib2070"><span class="elsevierStyleSup">215</span></a></p></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3&#46;2&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0235">Levosimendan and conditioning</span><p id="par1775" class="elsevierStylePara elsevierViewall">The conditioning mechanism of levosimendan is due to its interaction with ATP-sensitive K channels&#44; and not its contractile and vasodilating properties&#46; It does&#44; however&#44; improve contractility&#44; and is thus the only dual-action potassium channel opener and calcium sensitiser&#44; making it particularly useful in HF patients&#44; above all those with depressed LVEF&#46;<a class="elsevierStyleCrossRefs" href="#bib1915"><span class="elsevierStyleSup">184&#44;185&#44;202&#8211;204&#44;216&#44;217</span></a></p><p id="par1780" class="elsevierStylePara elsevierViewall">Levosimendan has been shown to have a preconditioning effect even at very low doses&#46; Tritapepe<a class="elsevierStyleCrossRefs" href="#bib1710"><span class="elsevierStyleSup">143&#44;144</span></a> and Zangrillo<a class="elsevierStyleCrossRef" href="#bib2085"><span class="elsevierStyleSup">218</span></a> have shown that in heart bypass surgery&#44; administration of a 24<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg bolus over 10<span class="elsevierStyleHsp" style=""></span>min reduces postoperative serum troponin levels&#46; Although this system could be considered effective&#44; it evidently does not improve contractility&#46;</p><p id="par1785" class="elsevierStylePara elsevierViewall">A new precondition&#44; method consisting in the administration of 0&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min levosimendan over 24<span class="elsevierStyleHsp" style=""></span>h prior to surgery&#44; has been tested in HF patients undergoing hip replacement surgery&#44;<a class="elsevierStyleCrossRef" href="#bib1405"><span class="elsevierStyleSup">82</span></a> in patients with low LVEF undergoing abdominal surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib1915"><span class="elsevierStyleSup">184&#44;185</span></a> and in high-risk patients with seriously compromised LV undergoing heart surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib2080"><span class="elsevierStyleSup">217&#44;219</span></a></p><p id="par1790" class="elsevierStylePara elsevierViewall">Although cohort size was small in these studies&#44; all reported positive haemodynamic outcomes&#44; albeit with insufficient power to evaluate mortality&#46; Nevertheless&#44; Landoni found decreased mortality following administration of levosimendan in patients taking catecholamines<a class="elsevierStyleCrossRef" href="#bib2095"><span class="elsevierStyleSup">220</span></a> and also in patients undergoing heart surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib2100"><span class="elsevierStyleSup">221&#8211;224</span></a></p><p id="par1795" class="elsevierStylePara elsevierViewall">There is no evidence to determine the appropriate time to start administration&#46; In patients with depressed LVEF&#44; we recommend early administration in a closely monitored setting&#44; ideally 8 or 12<span class="elsevierStyleHsp" style=""></span>h prior to surgery&#44; at a dose of 0&#46;1&#8211;0&#46;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#46;</p><p id="par1800" class="elsevierStylePara elsevierViewall">The issue of the ideal window of time for administration in still under debate&#46; A practical approach is to assume that some patients will be sent for surgery with no preparation&#44; while others will have been prepared&#46; It is important&#44; therefore&#44; to consider the many different effects of the drug and its onset of action&#58; dose-dependent early preconditioning&#44; inotropism lasting 4&#8211;6<span class="elsevierStyleHsp" style=""></span>h with continuous perfusion&#44; immunomodulation in 1<span class="elsevierStyleHsp" style=""></span>h according to in vitro and in vivo studies in HF patients&#46;</p><p id="par1805" class="elsevierStylePara elsevierViewall">Administration must be started as soon as possible&#44; provided the aim is to achieve certain goals&#46; If preoperative perfusion is indicated&#44; early intraoperative administration must not be contraindicated except for intolerance or evident risk&#46; There is not enough evidence to recommend systematic use of levosimendan in heart surgery&#46; Nevertheless&#44; it can be considered in high-risk surgery in patients with ischaemia-reperfusion injury where its positive inotropic effect can help postanaesthesia recovery&#46;</p></span></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;3&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0240">Postconditioning</span><p id="par1810" class="elsevierStylePara elsevierViewall">Postconditioning is similar to preconditioning&#44; although it has been far less studied in clinical practice&#46; The controlled ischaemia&#44; or drug&#44; is initially administered after the injury has occurred &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; In experiments and clinical practice&#44; various drugs have been shown to have postconditioning properties&#59; these include volatile anaesthetics&#44; nitrates&#44; opioids&#44; phosphodiesterase type 5 inhibitors&#44; adenosine&#44; diazoxide&#44; erythropoietin &#40;EPO&#41; and levosimendan&#46;<a class="elsevierStyleCrossRefs" href="#bib1735"><span class="elsevierStyleSup">148&#44;225&#44;226</span></a> Postconditioning&#44; however&#44; clearly has less clinical importance nowadays&#46;</p></span></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0245">Risk-reducing anaesthetic techniques</span><p id="par1815" class="elsevierStylePara elsevierViewall">Preoperative monitoring and haemodynamic optimisation must continue in the intra- and postoperative periods&#46; There is no need&#44; therefore&#44; to stress the importance of this&#46;</p><p id="par1820" class="elsevierStylePara elsevierViewall">Clinical guidelines on perioperative strategies in heart failure patients undergoing noncardiac surgery include few recommendations on intraoperative anaesthetic management&#44;<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">17&#44;227</span></a> although there is abundant information on ischaemic patients undergoing noncardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1390"><span class="elsevierStyleSup">79&#44;228</span></a></p><p id="par1825" class="elsevierStylePara elsevierViewall">Obviously&#44; locoregional anaesthesia in ophthalmology&#44; spinal anaesthesia or nerve blocks are associated with fewer complications than general anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib2140"><span class="elsevierStyleSup">229</span></a> The exception to this is carotid surgery&#44; where regional anaesthesia has not been shown to reduce neurological or cardiac complications&#46;<a class="elsevierStyleCrossRef" href="#bib2145"><span class="elsevierStyleSup">230</span></a> Studies comparing neuraxial blockade vs&#46; general anaesthesia have not confirmed the hypothesis that locoregional anaesthesia is associated with fewer anaesthesia-related complications&#46;</p><p id="par1830" class="elsevierStylePara elsevierViewall">Most anaesthetic techniques reduce sympathetic tone&#44; leading to vasodilation and reduction in tissue perfusion pressure&#46; This&#44; however&#44; will never cause tissue ischaemia&#46; Anaesthetic drugs do not appear to significantly impact the evolution of the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib2150"><span class="elsevierStyleSup">231&#44;232</span></a></p><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;4&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0250">Neuraxial blockade</span><p id="par1835" class="elsevierStylePara elsevierViewall">There is currently insufficient evidence to indicate the superiority of subarachnoid anaesthesia over general anaesthesia&#46;<a class="elsevierStyleCrossRefs" href="#bib2160"><span class="elsevierStyleSup">233&#8211;237</span></a> A number of studies have been carried out&#44; with varied findings&#58; some report positive findings in subgroups such as abdominal aortic aneurysm surgery&#44; while in others the results are largely similar&#46;<a class="elsevierStyleCrossRef" href="#bib2185"><span class="elsevierStyleSup">238</span></a> Thoracic epidural anaesthesia should be considered for patients with heart failure undergoing high-risk surgery&#46;</p><p id="par1840" class="elsevierStylePara elsevierViewall">In a meta-analysis&#44; Rodgers<a class="elsevierStyleCrossRef" href="#bib2190"><span class="elsevierStyleSup">239</span></a> showed less mortality with regional vs general anaesthesia&#44; although these findings were not echoed by Rigg<a class="elsevierStyleCrossRef" href="#bib2195"><span class="elsevierStyleSup">240</span></a> in an Australian study in 900 patients&#46;</p><p id="par1845" class="elsevierStylePara elsevierViewall">The aforementioned meta-analysis<a class="elsevierStyleCrossRef" href="#bib2190"><span class="elsevierStyleSup">239</span></a> has since been widely criticised due to the poor quality of 6 of the studies included&#44; which were precisely those with statistically significant differences&#46;<a class="elsevierStyleCrossRef" href="#bib2200"><span class="elsevierStyleSup">241</span></a></p><p id="par1850" class="elsevierStylePara elsevierViewall">The choice between general anaesthesia or neuraxial blockade will depend&#44; therefore&#44; on the particular pathophysiology of the heart condition and the goals sought&#46;<a class="elsevierStyleCrossRefs" href="#bib2205"><span class="elsevierStyleSup">242&#44;243</span></a> When reaching T4&#44; a reduction in cardiac sympathetic drive will appear&#44; which will subsequently override beta blockade&#46; However&#44; beta receptors are still able to respond to catecholamines&#46;</p><p id="par1855" class="elsevierStylePara elsevierViewall">Neuraxial blockade in obese patients with heart failure&#44; for example&#44; can cause hypoventilation&#46; This would aggravate their pathology&#44; irrespective of haemodynamic parameters&#46; Similarly&#44; general anaesthesia for minor surgery in a morbidly obese patient could encourage atelectasis&#44; which would also worsen existing pathology&#46;</p><p id="par1860" class="elsevierStylePara elsevierViewall">HF patients&#44; moreover&#44; are often on a regimen of antiplatelets or anticoagulants&#44; or simply antithrombosis prophylaxis&#46; In view of this&#44; a number of precautions should be taken both during administration of the blockade&#44; and during withdrawal of IV lines&#46;</p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;4&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0255">General anaesthesia</span><p id="par1865" class="elsevierStylePara elsevierViewall">Although evidence is scarce&#44; as mentioned above&#44; general anaesthesia has been identified as a risk factor in vascular surgery&#46;<a class="elsevierStyleCrossRef" href="#bib1250"><span class="elsevierStyleSup">51</span></a></p><p id="par1870" class="elsevierStylePara elsevierViewall">The cardiovascular effects of general anaesthesia include changes in central venous pressure&#44; arterial pressure and cardiac output&#44; and the appearance of arrhythmias&#46; The mechanisms behind these changes are&#58; decreased systemic vascular resistance&#44; decrease myocardial contractility&#44; decreased systolic volume&#44; and increased myocardial irritability&#46; Induction reduces systemic arterial pressure by 20&#8211;30&#37;&#44; intubation increases blood pressure by 20&#8211;30<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and drugs such as nitrous oxide can reduce cardiac output by up to 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib1240"><span class="elsevierStyleSup">49</span></a></p><p id="par1875" class="elsevierStylePara elsevierViewall">Although the findings of studies in volatile anaesthetics have been inconsistent&#44;<a class="elsevierStyleCrossRefs" href="#bib2215"><span class="elsevierStyleSup">244&#44;245</span></a> they have been shown to protect cardiac function and reduce myocardial injury&#46;<a class="elsevierStyleCrossRefs" href="#bib2150"><span class="elsevierStyleSup">231&#44;246&#44;247</span></a> The protective effect of these anaesthetics appears to be greater when they are used throughout the surgical procedure&#46;<a class="elsevierStyleCrossRef" href="#bib2155"><span class="elsevierStyleSup">232</span></a> The cardiac conditioning effects of volatile anaesthetics have been discussed in the section on conditioning&#46;</p></span></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0260">Postoperative risk reduction strategy</span><p id="par1880" class="elsevierStylePara elsevierViewall">Postoperative care is an integral part of the perioperative strategy&#46; It is focussed on pain management&#44; maintaining normothermia and nutritional status&#44; and preventing haemodynamic&#44; respiratory and kidney complications or any others that may arise&#46; In this guideline we will mainly focus on complications&#44; since these can aggravate existing HF&#46; Other aspects&#44; such as nutrition&#44; will not be dealt with&#44; as it is widely known that perioperative nutritional management is essential in surgical patients&#44; irrespective of their comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib2235"><span class="elsevierStyleSup">248</span></a> However&#44; analysis of nutritional strategies is not within the scope of this guideline&#46;</p><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0265">Pain management</span><p id="par1885" class="elsevierStylePara elsevierViewall">Analgesia is essential in surgical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib2240"><span class="elsevierStyleSup">249&#8211;253</span></a> Postoperative pain is thought to be inadequately managed<a class="elsevierStyleCrossRefs" href="#bib2250"><span class="elsevierStyleSup">251&#44;254</span></a> in up to 10&#37; of patients&#44; and this clearly delays recovery&#44; although the evidence that pain causes organ complications after surgery is less clear&#46;</p><p id="par1890" class="elsevierStylePara elsevierViewall">Epidural infusion of local anaesthetics and opioids and&#47;or alpha 2-agonists&#44; IV opioids alone or in combination with non-steroid anti-inflammatory drugs seem to be the most effective&#46;<a class="elsevierStyleCrossRef" href="#bib2240"><span class="elsevierStyleSup">249</span></a></p><p id="par1895" class="elsevierStylePara elsevierViewall">Postoperative analgesia should&#44; as far as possible&#44; be delivered intravenously&#46; Epidural analgesia has clear advantages over other options&#59; it reduces postoperative stress&#44; improves respiratory complications and shortens ICU stay&#46;<a class="elsevierStyleCrossRef" href="#bib2270"><span class="elsevierStyleSup">255</span></a> The quality of regional analgesics for postoperative pain management is beyond dispute&#59; however&#44; the benefits of invasive analgesic techniques should be weighed against the risk of haematoma in patients on antithrombotic drugs or with coagulation disturbances&#46;</p><p id="par1900" class="elsevierStylePara elsevierViewall">Patient-controlled analgesia &#40;PCA&#41; is a valid option&#44; although we consider it to be less effective&#44; and more suitable for patients and situations where regional anaesthesia is not advised&#46;<a class="elsevierStyleCrossRefs" href="#bib2250"><span class="elsevierStyleSup">251&#44;256</span></a></p><p id="par1905" class="elsevierStylePara elsevierViewall">Non-steroidal anti-inflammatory drugs and COX-2 inhibitors have the potential for promoting heart and renal failure as well as thromboembolic events and should be avoided in patients with myocardial ischaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib2240"><span class="elsevierStyleSup">249&#44;251&#44;257&#44;258</span></a></p><p id="par1910" class="elsevierStylePara elsevierViewall">Use of non-steroidal anti-inflammatory drugs and COX-2 inhibitors for post-operative pain control is not recommended in patients with renal and heart failure&#44; myocardial ischaemia&#44; elderly patients&#44; as well as in patients taking diuretics or haemodynamically unstable&#46; The risk of kidney failure is low&#44; however&#44; if these drugs are avoided in patients with compromised kidney function and poor tissue perfusion&#46;<a class="elsevierStyleCrossRefs" href="#bib2280"><span class="elsevierStyleSup">257&#8211;259</span></a> The risk of worsening HF appears to be similar in both&#46; We consider it advisable to avoid these drugs in patients with kidney failure&#44; HF or unstable angina</p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0270">Hypothermia and hypoxia</span><p id="par1915" class="elsevierStylePara elsevierViewall">Hypothermia is a significant postoperative complication in HF patients&#46; It leads to increase oxygen consumption&#44; and consequently demand&#44; and increases the incidence of haemorrhage and surgical site infection&#46;<a class="elsevierStyleCrossRef" href="#bib2295"><span class="elsevierStyleSup">260</span></a></p><p id="par1920" class="elsevierStylePara elsevierViewall">All clinicians will be familiar with the dramatic effect of hypoxia on any patient&#46; The most effective treatment for hypoxia is analgesia&#44; physiotherapy&#44; oxygenation&#44; and invasive and non-invasive ventilation&#46;</p><p id="par1925" class="elsevierStylePara elsevierViewall">Prophylactic physiotherapy&#44; positive end expiratory pressure or non-invasive positive pressure ventilation have not been shown to improve postoperative pulmonary function&#46; All the foregoing methods are effective in treating postoperative respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib2300"><span class="elsevierStyleSup">261</span></a> The effectiveness of the administration of high-concentration supplemental oxygen is less clear&#46;<a class="elsevierStyleCrossRefs" href="#bib2305"><span class="elsevierStyleSup">262&#44;263</span></a></p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0275">Postoperative haemodynamic complications&#46; Acute HF</span><p id="par1930" class="elsevierStylePara elsevierViewall">Haemodynamic problems are among the most common&#44; and possible the most serious&#44; postoperative complications&#46;<a class="elsevierStyleCrossRef" href="#bib2315"><span class="elsevierStyleSup">264</span></a> They can be caused by many different factors&#44; ranging from simple vasodilation to cardiogenic shock<elsevierMultimedia ident="tb0075"></elsevierMultimedia></p><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0280">Postoperative hypotension&#47;hypertension</span><p id="par1940" class="elsevierStylePara elsevierViewall">Hypotension is common in patients with low cardiac output&#44; and can usually be corrected with medication to treat low cardiac output&#46; However&#44; there is another relatively common postoperative situation&#44; namely systemic inflammatory response syndrome &#40;SIRS&#41;&#46; In cardiovascular terms&#44; SIRS causes increase cardiac output and decreased vascular resistance&#46; Neuraxial blockade techniques will aggravate SIRS&#59; low-dose alpha mimetics &#40;phenylephrine&#44; norepinephrine&#41; can be used to boost arterial pressure and prevent vasodilation from prolonging increased CO&#46;<a class="elsevierStyleCrossRef" href="#bib2320"><span class="elsevierStyleSup">265</span></a> The situation can usually be corrected in a few hours&#44; although it is important to bear in mind that SIRS can ultimately lead to multiple organ failure&#46;</p><p id="par1945" class="elsevierStylePara elsevierViewall">Postoperative hypertension &#40;HTN&#41; is also a common finding and has many different possible causes&#46; Anaesthetic and analgesic techniques have a major impact on these symptoms&#46; HTN increases myocardial VO<span class="elsevierStyleInf">2</span>&#44; and thus the risk of ischaemia&#46; Patients with HTN are at risk for developing associated morbidity&#58; increased incidence of stroke&#59; LV failure&#59; increased incidence of arrhythmia&#59; bleeding through vascular sutures&#44; and increased risk of haemorrhage&#46;</p><p id="par1950" class="elsevierStylePara elsevierViewall">Analgesics&#44; alpha- and beta-blockers&#44; and nitrates are the drugs most commonly using in the postoperative period&#46;</p></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0285">Postoperative low cardiac output syndrome</span><p id="par1955" class="elsevierStylePara elsevierViewall">Low cardiac output is a complex complication&#44; as most cardiac complications ultimately lead to this situation&#46; It is extremely common&#44; with a multifactorial aetiology in which the acute postoperative volaemic changes so often seen in these patients plays a fundamental role&#46; Low cardiac output in the postoperative period&#44; however&#44; can vary greatly in terms of seriousness and prognosis&#44; ranging from a minor complication to full cardiogenic shock&#46; <a class="elsevierStyleCrossRef" href="#tbl0055">Table 9</a> shows the most common causes of this syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib1255"><span class="elsevierStyleSup">52</span></a> Low cardiac output can be defined as the situation in which cardiac output is insufficient for metabolic demands&#46; It is difficult to determine the exact threshold for low cardiac output in the immediate postoperative period&#46; This is because sedation and hypothermia greatly diminish overall O<span class="elsevierStyleInf">2</span> consumption&#44; and the patient may be receiving all the O<span class="elsevierStyleInf">2</span> they need with a relatively low cardiac output&#46; Postoperative low cardiac output is usually defined as a cardiac index of less than 2&#46;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#46;</p><elsevierMultimedia ident="tbl0055"></elsevierMultimedia><p id="par1960" class="elsevierStylePara elsevierViewall">Postoperative low output is treated in much the same way as any other low output situation&#58; optimise preload&#44; control heart rate&#44; optimise vascular resistance and improve contractility&#46;</p><p id="par1965" class="elsevierStylePara elsevierViewall">The usual treatment for low output is to increase preload and administer catecholamines&#46; Levosimendan has been shown to be more effective than dobutamine<a class="elsevierStyleCrossRefs" href="#bib2010"><span class="elsevierStyleSup">203&#44;266&#44;267</span></a> and phosphodiesterase inhibitors&#44;<a class="elsevierStyleCrossRef" href="#bib2075"><span class="elsevierStyleSup">216</span></a> particularly in patients with depressed LVEF&#46;<a class="elsevierStyleCrossRefs" href="#bib2075"><span class="elsevierStyleSup">216&#44;266&#8211;325</span></a> The current trend is to administer between 0&#46;1 and 0&#46;2<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min levosimendan without a loading dose&#46;</p><p id="par1970" class="elsevierStylePara elsevierViewall">Vasodilators&#44; such as nitroglycerine &#40;NTG&#41; decrease preload and afterload and increase systolic volume&#46; It should only be used in patients with systolic arterial pressure greater than 110<span class="elsevierStyleHsp" style=""></span>mmHg&#44; as it causes hypothermia&#44; a condition that is associated with increased mortality in HF patients&#44; particularly those with aortic or mitral stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib1225"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0290">Acute heart failure&#44; left ventricular failure and cardiogenic pulmonary oedema</span><p id="par1975" class="elsevierStylePara elsevierViewall">Acute HF &#40;AHF&#41; describes the rapid onset or worsening of signs and symptoms of HF&#46; AHF is one of the postoperative problems associated with HF patients&#46;<a class="elsevierStyleCrossRef" href="#bib2340"><span class="elsevierStyleSup">269</span></a> It is extremely serious&#44; and can be triggered by many different factors&#44; which are summarised in <a class="elsevierStyleCrossRef" href="#tbl0060">Table 10</a>&#46; <a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a> shows the treatment schedule for AHF&#46; <a class="elsevierStyleCrossRef" href="#tbl0065">Table 11</a> shows the therapeutic goals&#46; Nevertheless&#44; we disagree with the indiscriminate use of the term acute HF in surgical patients&#44; because it is not entirely accurate&#46; We prefer&#44; instead&#44; to refer to hypotension&#44; hypertension&#44; low output&#44; cardiogenic shock and arrhythmia&#46;</p><elsevierMultimedia ident="tbl0060"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0065"></elsevierMultimedia><p id="par1980" class="elsevierStylePara elsevierViewall">Pulmonary oedema is the most important clinical manifestation of acute HF&#46; It can be defined as a rapid deterioration of the signs and symptoms of HF in previously diagnosed patients&#44; although it often appears in previously undiagnosed patients&#46;<a class="elsevierStyleCrossRef" href="#bib2345"><span class="elsevierStyleSup">270</span></a> Postoperative dyspnoea is not synonymous with either HF or pulmonary oedema&#44; since it can have various different causes &#40;<a class="elsevierStyleCrossRef" href="#tbl0070">Table 12</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0070"></elsevierMultimedia><p id="par1985" class="elsevierStylePara elsevierViewall">Myocardial ischaemia must immediately be ruled out in all postoperative patients with pulmonary oedema&#46; Myocardial ischaemia is usually diagnosed on the basis of ECG monitoring&#44; echo studies&#44; serial enzymes and coronary angiography&#46;</p><p id="par1990" class="elsevierStylePara elsevierViewall">Intraoperative fluid balance must also be evaluated in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib2350"><span class="elsevierStyleSup">271</span></a> Diagnosis and treatment must be practically simultaneous&#46; <a class="elsevierStyleCrossRef" href="#tbl0075">Table 13</a> shows the drugs usually used&#44; apart from mechanical systems&#44; to correct fluid imbalance&#46;</p><elsevierMultimedia ident="tbl0075"></elsevierMultimedia><p id="par1995" class="elsevierStylePara elsevierViewall">LV failure with acute pulmonary oedema is an emergency situation that must be addressed immediately to ensure oxygenation&#44; often with mechanical ventilation&#44; and improving LV function with catecholamines and&#47;or vasodilators &#40;if tolerated&#41;&#46; The use of intra-aortic balloon counterpulsation is important in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib2355"><span class="elsevierStyleSup">272</span></a> Diuretics can initially improve symptoms by reducing congestion&#46; However&#44; they must be used with caution&#44; since they can often cause relative hypovolaemia&#44; which compromises CO&#46;</p></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0295">Cardiogenic shock</span><p id="par2000" class="elsevierStylePara elsevierViewall">Cardiogenic shock is an extreme form of acute HF and LV failure&#46; It is characterised by persistent and progressive loss of blood pressure with generalised&#44; severe decrease of tissue perfusion beyond the limits necessary to maintain vital organ function at rest&#46;<a class="elsevierStyleCrossRef" href="#bib1280"><span class="elsevierStyleSup">57</span></a> Onset of shock is relatively acute and extremely serious&#46; The clinical criteria for diagnosing cardiogenic shock are shown in <a class="elsevierStyleCrossRef" href="#tbl0080">Table 14</a>&#46; Treatment must be based on the principles shown in <a class="elsevierStyleCrossRef" href="#tbl0085">Table 15</a>&#46; Cardiogenic shock is treated mainly with sympathomimetic drugs&#44; dopamine&#44; dobutamine&#44; adrenaline and norepinephrine&#46; Phosphodiesterase inhibitors have a far more limited effect&#46;</p><elsevierMultimedia ident="tbl0080"></elsevierMultimedia><elsevierMultimedia ident="tbl0085"></elsevierMultimedia><p id="par2005" class="elsevierStylePara elsevierViewall">In situations where mechanical circulatory support&#44; intra-aortic balloon pump or ventricular assist devices are used&#44; levosimendan has been shown to significantly improve haemodynamics&#44;<a class="elsevierStyleCrossRef" href="#bib2360"><span class="elsevierStyleSup">273</span></a> although there is insufficient research to give this recommendation a high level of evidence&#46; Recent studies have found that the intra-aortic balloon pump did not reduce mortality in cardiogenic shock following acute myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib2365"><span class="elsevierStyleSup">274</span></a></p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5&#46;5&#46;3&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0300">Myocardial ischaemia and acute myocardial infarction</span><p id="par2010" class="elsevierStylePara elsevierViewall">Myocardial ischaemia is a common problem in noncardiac surgery in patients with ischaemic heart disease&#46; One in every six adult surgical patients is at risk of presenting myocardial ischaemia&#46; Incidence of the disease ranges from 18&#37; to 65&#37;&#46; Studies suggest that between 0&#46;1&#37; and 5&#46;6&#37; of these will develop postoperative myocardial infarction&#44; with a mortality rate ranging from 17&#37; to 37&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib1385"><span class="elsevierStyleSup">78</span></a></p><p id="par2015" class="elsevierStylePara elsevierViewall">Postoperative myocardial infarction is diagnosed on the basis of the findings of 12-lead ECG study and CPK-MB and troponin levels&#46; However&#44; non-ischaemia-related ECG changes&#44; such as T-wave abnormalities&#44; are often found post-surgery&#44; which is why these changes alone cannot confirm and&#47;or support a diagnosis of myocardial ischaemia&#46; To diagnose postoperative infarction&#44; ECG findings must show the presence of new Q waves and&#47;or persistent ST-T wave changes&#46; Twelve-lead ECG&#44; moreover&#44; has low sensitive for the diagnosis of postoperative infarction in the presence of conduction disorders &#40;bundle branch block&#41; and pacemakers&#46; In these cases&#44; echocardiography is extremely useful&#46;</p><p id="par2020" class="elsevierStylePara elsevierViewall">The main goal should be&#44; as far as possible&#44; percutaneous or surgical revascularization&#46; The recommended therapeutic manoeuvres are shown in <a class="elsevierStyleCrossRef" href="#tbl0090">Table 16</a>&#46; The use of inotropes and ventricular assist devices are shown in <a class="elsevierStyleCrossRef" href="#tbl0095">Table 17</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">17&#44;275</span></a></p><elsevierMultimedia ident="tbl0090"></elsevierMultimedia><elsevierMultimedia ident="tbl0095"></elsevierMultimedia></span></span></span></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6</span><span class="elsevierStyleSectionTitle" id="sect0305">Specific pathologies in heart failure patients</span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0310">Valve disease</span><p id="par2025" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0080"></elsevierMultimedia></p><p id="par2035" class="elsevierStylePara elsevierViewall">Valvular heart disease &#40;VHD&#41; is a risk factor in patients undergoing noncardiac surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">17&#44;21</span></a> Echocardiography should be performed on any prospective noncardiac surgery patient with known or suspected VHD&#46; In patients with VHD or prosthetic valves scheduled for noncardiac surgery&#44; endocarditis prophylaxis should be administered to prevent bacteraemia&#46;<a class="elsevierStyleCrossRefs" href="#bib1105"><span class="elsevierStyleSup">22&#44;28</span></a></p><p id="par2040" class="elsevierStylePara elsevierViewall">In patients taking anticoagulants&#44; it is important to remember that those with mitral valve prosthesis and atrial fibrillation are at high risk for thrombosis&#46; Therefore&#44; it is imperative to suspend oral anticoagulants and replace with an appropriate heparin regimen&#46;</p><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0315">Aortic stenosis</span><p id="par2045" class="elsevierStylePara elsevierViewall">Aortic stenosis is the most common VHD in Europe&#46; Severe stenosis is defined as a valve area of less than 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> or 0&#46;6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#46; Aortic stenosis is an independent risk factor for increased perioperative morbidity and mortality in noncardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib2375"><span class="elsevierStyleSup">276</span></a></p><p id="par2050" class="elsevierStylePara elsevierViewall">Neuraxial blockade is usually very poorly tolerated due to ensuing vasodilation&#44; and experts recommend the use of invasive haemodynamic monitoring techniques&#46; In the case of elective surgery in patients with symptoms&#44; valve replacement should be considered before surgery&#46; In oncologic surgery&#44; however&#44; the risk&#47;benefit ratio should be carefully evaluated&#46; In these patients&#44; transcatheter aortic valve implantation can be a valid option&#44; although there is little scientific evidence to support this&#46;<a class="elsevierStyleCrossRefs" href="#bib1100"><span class="elsevierStyleSup">21&#44;26</span></a></p></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0320">Mitral stenosis</span><p id="par2055" class="elsevierStylePara elsevierViewall">Mitral stenosis is far less complicated than aortic stenosis&#46; The risk of noncardiac surgery is relatively low in these patients&#44; compared with aortic stenosis&#46;</p><p id="par2060" class="elsevierStylePara elsevierViewall">Preoperative surgical correction of mitral stenosis is not required in patients with a valve area greater than 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> and systolic pressure of less than 50<span class="elsevierStyleHsp" style=""></span>mmHg&#46; In these patients&#44; control of heart rate is essential to avoid tachycardia&#44; which may cause pulmonary oedema&#46;</p><p id="par2065" class="elsevierStylePara elsevierViewall">Spinal anaesthesia is often contraindicated in these patients&#44; due to their need for anticoagulation therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib1100"><span class="elsevierStyleSup">21&#44;277</span></a></p></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;1&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0325">Aortic regurgitation and mitral regurgitation</span><p id="par2070" class="elsevierStylePara elsevierViewall">Non-significant aortic regurgitation and mitral regurgitation are independent risk factors for cardiovascular complications in noncardiac surgery&#46; Noncardiac surgery can be performed without additional risk in stable&#44; asymptomatic patients with preserved LV function&#44; even in the presence of severe aortic mitral regurgitation&#46; Complications increase significantly&#44; however&#44; when LVEF is below 30&#37;&#46; In this case&#44; noncardiac surgery should be performed only when strictly necessary&#46;<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">21</span></a></p></span></span><span id="sec0330" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0330">Hypertension</span><p id="par2075" class="elsevierStylePara elsevierViewall">Arterial hypertension is not considered an independent risk factor for cardiovascular complications in noncardiac surgery&#44; although these patients should be screened for organ damage and evidence of associated cardiovascular disease&#46; If found&#44; treatment should be given in accordance with usual guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib1090"><span class="elsevierStyleSup">19</span></a></p><p id="par2080" class="elsevierStylePara elsevierViewall">Interruption of background hypertension therapy due to surgery should be kept to a minimum&#46; In patients with SAP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>180<span class="elsevierStyleHsp" style=""></span>mmHg and DAP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mmHg&#44; there is no evidence that suspension or postponement of surgery will reduce the risk of complications&#46; Above these levels&#44; experts agree that surgery should be suspended while antihypertensive treatment is optimised&#46;</p></span><span id="sec0335" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0335">Patients with right ventricular failure&#46; Right-sided heart failure</span><p id="par2085" class="elsevierStylePara elsevierViewall">The right ventricle &#40;RV&#41; is highly sensitive to changes in loading conditions&#44; above all afterload&#44; and has little inotropic reserve&#46; Because of this&#44; pulmonary arterial hypertension &#40;PH&#41; is the most common cause of RV failure&#46;<a class="elsevierStyleCrossRefs" href="#bib2385"><span class="elsevierStyleSup">278&#44;279</span></a> Other causes of RV failure include ischaemia&#44; acute or chronic volume overload and an abrupt increase in afterload&#46; <a class="elsevierStyleCrossRef" href="#tbl0100">Table 18</a> shows the main predisposing factors for right ventricle failure&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">29&#44;280&#44;281</span></a></p><elsevierMultimedia ident="tbl0100"></elsevierMultimedia><span id="sec0340" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;3&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0340">Treatment of right ventricular dysfunction</span><p id="par2090" class="elsevierStylePara elsevierViewall">Treatment of RV dysfunction is focussed on reducing afterload&#44; which will be reviewed in the section on PH&#44; and on preserving or increasing ventricular contractility&#44; provided preload is adequate and coronary perfusion pressure remains stable to prevent systemic arterial hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">29</span></a></p><p id="par2095" class="elsevierStylePara elsevierViewall">Certain inotropes&#44; such as dobutamine&#44; milrinone and isoproterenol&#44; reduce PVR but also SVR&#44; which is why they are sometimes combined with norepinephrine or phenylephrine&#46; Isoproterenol greatly increases myocardial oxygen uptake and causes tachycardia&#44; which restricts its use&#46; Adrenaline and dopamine have a dose-dependent alpha-adrenergic effect&#46; At high doses&#44; therefore&#44; they increase PVR&#44; and a pulmonary vasodilator may be needed&#46;</p><p id="par2100" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the therapeutic goal is to reduce pulmonary vascular resistance&#44; facilitate contractility&#44; and maintain arterial pressure at an appropriate level&#46; <a class="elsevierStyleCrossRef" href="#tbl0105">Table 19</a> shows the drugs most commonly used in these indications&#46;</p><elsevierMultimedia ident="tbl0105"></elsevierMultimedia><p id="par2105" class="elsevierStylePara elsevierViewall">In patients with poor response to these therapies&#44; implantation of an intra-aortic balloon pump should be considered to increase coronary perfusion pressure&#46; Alternatively&#44; an extracorporeal assist device&#44; such as an extracorporeal membrane oxygenation &#40;ECMO&#41; system or ventricular assist device may be considered&#46;<a class="elsevierStyleCrossRef" href="#bib2405"><span class="elsevierStyleSup">282</span></a></p></span></span><span id="sec0345" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0345">Pulmonary arterial hypertension</span><p id="par2110" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0085"></elsevierMultimedia></p><p id="par2120" class="elsevierStylePara elsevierViewall">Pulmonary hypertension &#40;PH&#41; is defined as a mean pulmonary arterial pressure &#40;PAPm&#41; greater than 25<span class="elsevierStyleHsp" style=""></span>mmHg at rest&#44; or &#62;30<span class="elsevierStyleHsp" style=""></span>mmHg with exercise&#46; It is characterised by a progressive increase in pulmonary arterial pressure &#40;PAP&#41;&#44; together with a variable degree of vasoconstriction&#44; pulmonary vascular remodelling and in situ thrombosis&#46;</p><p id="par2125" class="elsevierStylePara elsevierViewall">Specific consideration should be given to patients with PH due to the high risk of perioperative morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib2390"><span class="elsevierStyleSup">279&#8211;285</span></a> The most common morbidities associated with this disease are acute respiratory failure &#40;28&#37;&#41;&#44; arrhythmia &#40;12&#37;&#41; and CHF &#40;11&#37;&#41;&#46; The most common contributory causes of death in this group are left ventricular failure &#40;50&#37; of patients&#41; and respiratory failure&#46; History of pulmonary embolism&#44; NYHA functional class<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>II&#44; high- and intermediate-risk surgery&#44; and anaesthesia lasting over 3<span class="elsevierStyleHsp" style=""></span>h&#44; are predictors of early mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib2390"><span class="elsevierStyleSup">279&#8211;285</span></a></p><p id="par2130" class="elsevierStylePara elsevierViewall">Right atrial pressure higher than left atrial pressure can lead to a right-to-left intracardiac shunting through a patent foramen ovale &#40;in 30&#37; of patients&#41; or an atrial septal defect causing arterial desaturation&#46; This is known as Eisenmenger&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib2425"><span class="elsevierStyleSup">286</span></a> Medical guidelines provide very little information on patients with PH requiring surgery&#44; however&#44; all authors agree on the high risk associated with the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">29</span></a></p><span id="sec0350" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;4&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0350">Risk limitation in patients with pulmonary hypertension&#46; Preoperative assessment and optimisation</span><p id="par2135" class="elsevierStylePara elsevierViewall">The preoperative assessment of patients with PH is the same as the protocol recommended for HF patients&#44; with the exception of arterial blood gas measurement&#44; due to the respiratory impairment commonly found in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">29&#44;287</span></a> Echocardiography is the initial or routine study of choice&#46; Right heart catheterisation is standard for the diagnosis of PH&#46; Catheterisation can confirm the initial suspicion&#44; evaluate haemodynamic impairment&#44; help to establish a prognosis&#44; and measure pulmonary vasoreactivity&#46;</p><p id="par2140" class="elsevierStylePara elsevierViewall">In these patients&#44; optimisation will depend on the severity of PH and the underlying disease&#46; Surgery can be scheduled provided the patient is stable&#44; with no recent aggravation of the condition&#46; Continuation of all pulmonary vasodilator medication is essential<a class="elsevierStyleCrossRef" href="#bib2415"><span class="elsevierStyleSup">284</span></a>&#58; calcium channel blockers&#44; prostanoids&#44; endothelin receptor antagonists&#44; and phosphodiesterase 5 inhibitors&#46; If prolonged interruption s expected &#40;more than 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; oral therapy should be switched to IV&#46; Anticoagulants&#44; diuretics and digitalis will either be continued or suspended&#44; as recommended in other HF patients&#46;</p><p id="par2145" class="elsevierStylePara elsevierViewall">If PH diagnosis is made immediately prior to urgent surgery&#44; 50&#8211;100<span class="elsevierStyleHsp" style=""></span>mg of oral sildenafil can be given&#46;<a class="elsevierStyleCrossRefs" href="#bib2435"><span class="elsevierStyleSup">288&#44;289</span></a></p></span><span id="sec0355" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;4&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0355">Anaesthetic techniques in patients with pulmonary hypertension</span><p id="par2150" class="elsevierStylePara elsevierViewall">Optimised monitoring technique discussed above should be used&#46; In our opinion&#44; pulmonary artery catheterisation&#44; which may be disputed in conventional HF&#44; is indicated in patients with severe PH undergoing intermediate- or high-risk surgery&#46; Intraoperative TEE is recommended&#44; provided it is performed by an expert practitioner&#46; We consider central venous pressure &#40;CVP&#41; to be imperative&#44; albeit in combination with other measurements&#46;</p><p id="par2155" class="elsevierStylePara elsevierViewall">Anaesthetic technique should always be based on the following principles&#58; avoid causing hypotension due to excessive vasodilation&#44; maintain preloading&#44; avoid tachycardia and loss of sinus rhythm&#44; avoid anaemia&#44; and avoid acidosis and hypoxia&#46; Nerve and plexus blockade is usually preferred to neuraxial or general anaesthesia&#44; while neuraxial blockade should be chosen over general anaesthesia&#46; When using regional techniques&#44; it is important to consider coagulation status&#44; and bear in mind that systemic epoprostenol has a powerful antiplatelet action&#46; In addition to regional techniques&#44; it is also important to ensure the patient is adequately ventilated and oxygenated to prevent an increase in PVR&#46; Prevention of factors that can increase PVR&#44; such as hypoxaemia&#44; hypercapnia&#44; acidosis&#44; hypothermia and superficial anaesthesia is equally even more important than the anaesthetic technique itself&#46;<a class="elsevierStyleCrossRef" href="#bib2445"><span class="elsevierStyleSup">290</span></a></p><p id="par2160" class="elsevierStylePara elsevierViewall">Intradural anaesthesia is not recommended&#44; as it is associated with more abrupt haemodynamic changes&#59; however&#44; at low doses&#44; it can minimise hypotension&#46; Hypotension secondary to nerve blockade is controlled by adjusting volaemia and with alpha adrenergics such as norepinephrine and phenylephrine&#46; Ephedrine and alpha- and beta-adrenergic receptor&#44; are also useful if PH is associated with bradycardia&#46; A combination of general and epidural anaesthesia is a good choice&#44; and also facilitates postoperative analgesic management&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">29&#44;291</span></a></p><p id="par2165" class="elsevierStylePara elsevierViewall">Epidural anaesthesia should consist of a combination of local anaesthetics and opioids to improve the analgesic effect&#44; and to reduce local anaesthetic dosage and the haemodynamic consequences of nerve blockade&#46; The main risks associated with this technique are venous return impairment&#44; hypotension&#44; and the risk of cardioaccelerator fibre blockade&#46;</p><p id="par2170" class="elsevierStylePara elsevierViewall">Thoracic epidural anaesthesia does not affect PVR&#46; Nevertheless&#44; high thoracic epidural should not be used in patients with PH&#44; because blockade of the sympathetic cardiac nerves at T1 and T4 has a negative inotropic and chronotropic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib2205"><span class="elsevierStyleSup">242&#44;243&#44;279&#44;292&#44;293</span></a></p><p id="par2175" class="elsevierStylePara elsevierViewall">General anaesthesia is unavoidable in many surgical interventions&#46; In these patients&#44; it gives good haemodynamic and respiratory control&#46;<a class="elsevierStyleCrossRef" href="#bib2465"><span class="elsevierStyleSup">294</span></a> Etomidate and propofol are the most commonly used induction drugs&#44; together with benzodiazepines&#46; Anaesthesia should be induced gradually to prevent excessive vasodilation&#46; The intubation site can be desensitised with opioids and lidocaine&#46;</p><p id="par2180" class="elsevierStylePara elsevierViewall">No clear advantage has been found between volatile anaesthetics and total intravenous anaesthesia &#40;TIVA&#41;&#46; Nitrous oxide is usually contraindicated in adults due to its depressor effect on contractility and pulmonary vasoconstriction&#46;</p><p id="par2185" class="elsevierStylePara elsevierViewall">Muscle relaxation should be maintained with non-histamine liberating drugs&#46; Mechanical ventilation should be set to low PEEP levels&#44; between 4 and 8<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; to minimise atelectasis and optimise alveolar recruitment with minimal intrathoracic pressure increase to avoid compromising venous return&#46; Hyperinflation due to high PEEP levels&#44; atelectasis and hypercapnia increase PVR&#46;</p></span><span id="sec0360" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;4&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0360">Haemodynamic control&#46; Pulmonary vasodilators</span><p id="par2190" class="elsevierStylePara elsevierViewall">Global&#44; not only right-side&#44; haemodynamic control is fundamental&#46; Many surgical and anaesthesia manoeuvres can lead to a sudden increase in PVR&#44; and subsequently RV failure&#46; Although intravenous vasodilators are effective in reducing PVR&#44; their clinical usefulness is limited by their tendency to cause systemic hypotension&#46; They cause diffuse pulmonary vascular dilation&#44; including unventilated areas&#44; inhibit hypoxic pulmonary vasoconstriction&#44; thus increasing intrapulmonary shunt and restricting oxygenation&#46; Prostaglandins&#44; being powerful platelet aggregation inhibitors&#44; are more effective&#46;<a class="elsevierStyleCrossRef" href="#bib2470"><span class="elsevierStyleSup">295</span></a> Epoprostenol has an extremely short half-life &#40;2&#8211;3<span class="elsevierStyleHsp" style=""></span>min&#41; and is administered in continuous IV infusion &#40;4&#8211;10<span class="elsevierStyleHsp" style=""></span>ng&#47;kg&#47;min&#41;&#46; Nitroglycerine &#40;0&#46;1&#8211;7<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41; and sodium nitroprusside &#40;0&#46;1&#8211;4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41; have traditionally been used&#46;</p><p id="par2195" class="elsevierStylePara elsevierViewall">Volatile pulmonary vasodilators do not cause systemic hypotension and improve the ventilation&#47;perfusion ratio and blood oxygen levels by increasing blood circulation in ventilated areas&#46; They are currently the treatment of choice&#46;<a class="elsevierStyleCrossRef" href="#bib2475"><span class="elsevierStyleSup">296</span></a></p><p id="par2200" class="elsevierStylePara elsevierViewall">Inhaled nitrous oxide at a concentration of 10&#8211;40<span class="elsevierStyleHsp" style=""></span>ppm is very effective&#46; It has a half-life of 2&#8211;6<span class="elsevierStyleHsp" style=""></span>s&#44; and can therefore be administered in continuous infusion&#46; It has little bronchodilator activity&#46; It can cause clinical toxicity due to methemoglobinaemia and production of nitrogen dioxide &#40;NO<span class="elsevierStyleInf">2</span>&#41; and hydroxyl radicals&#46; On a technical level&#44; it is difficult to administer&#44; and requires monitoring of NO&#44; O<span class="elsevierStyleInf">2</span> and NO<span class="elsevierStyleInf">2</span> levels&#46;<a class="elsevierStyleCrossRef" href="#bib2480"><span class="elsevierStyleSup">297</span></a></p><p id="par2205" class="elsevierStylePara elsevierViewall">Volatile prostaglandins are administered via a nebuliser connected to the inspiratory limb of the ventilator&#46; Prostaglandin has a half-life of 3&#8211;6<span class="elsevierStyleHsp" style=""></span>min&#46; It is administered by intermittent inhalation at a dose of 14&#8211;17<span class="elsevierStyleHsp" style=""></span>&#956;g for 15<span class="elsevierStyleHsp" style=""></span>min&#44; repeated every hour&#44; or as continuous inhalation &#40;50<span class="elsevierStyleHsp" style=""></span>ng&#47;kg&#47;min&#41;&#46; Iloprost &#40;10&#8211;20<span class="elsevierStyleHsp" style=""></span>&#956;g&#41; is nebulised for 15<span class="elsevierStyleHsp" style=""></span>min&#46; It is a prostacyclin analogue that is stable at room temperature and normal lighting conditions&#44; and has a half-life of 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min&#46; Its effect lasts for 60&#8211;90<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib2485"><span class="elsevierStyleSup">298&#44;299</span></a></p><p id="par2210" class="elsevierStylePara elsevierViewall">Other inhaled selective pulmonary vasodilators are NTG&#44; sodium nitroprusside and milrinone&#46; Combination NO and inhaled prostacyclin therapy&#44; or the combination of one of these with a phosphodiesterase inhibitor&#44; inhaled milrinone or IV dipyridamole&#44; are also beneficial for maintaining PVR&#46; NO and inhaled prostaglandins must be withdrawn gradually to avoid the possibility of rebound pulmonary hypertension&#46; It must be administered with caution in patients with LV dysfunction&#44; since it can cause acute pulmonary oedema&#46;</p><p id="par2215" class="elsevierStylePara elsevierViewall">Patients with right ventricular dysfunction and moderate or severe PH undergoing intermediate- or high-risk surgery will be candidates for preconditiong with levosimendan&#44; which also rapidly reduces PVR&#44; improves RV function&#44; and is effective for several days&#46;<a class="elsevierStyleCrossRefs" href="#bib2405"><span class="elsevierStyleSup">282&#44;300&#8211;303</span></a></p><p id="par2220" class="elsevierStylePara elsevierViewall">Levosimendan has been clinically proven to be effective in RV infarction&#44;<a class="elsevierStyleCrossRefs" href="#bib1540"><span class="elsevierStyleSup">109&#44;304&#8211;307</span></a> ARDS<a class="elsevierStyleCrossRef" href="#bib2535"><span class="elsevierStyleSup">308</span></a> or following mitral valve surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib2540"><span class="elsevierStyleSup">309&#8211;311</span></a> Norepinephrine and phenylephrine are most commonly used to maintain vascular resistance&#46; Norepinephrine has the added advantage of have a positive inotropic action&#46; Aside from these effects&#44; levosimendan can impede progression of the vascular remodelling typical of PH&#44; thus reducing vascular wall thickening&#46;<a class="elsevierStyleCrossRef" href="#bib2555"><span class="elsevierStyleSup">312</span></a></p></span><span id="sec0365" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;4&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0365">Postoperative care in surgical pulmonary hypertension patients</span><p id="par2225" class="elsevierStylePara elsevierViewall">Decompensation in the postoperative period can be caused by a gradual increase in pulmonary vascular tone&#44; acute pulmonary vasospasm&#44; pulmonary thromboembolism&#44; arrhythmia&#44; elevated sympathetic tone&#44; and volaemic variations&#46; Respiratory failure is the most common postoperative complication&#46;</p><p id="par2230" class="elsevierStylePara elsevierViewall">Hypoxaemia&#44; hypercapnia&#44; hypotension&#44; hypovolaemia and pain should be avoided&#46; Pulmonary vasodilation medication started during surgery should be withdrawn gradually&#44; and chronic vasodilation treatment should be restarted as soon as possible&#46;<a class="elsevierStyleCrossRef" href="#bib2455"><span class="elsevierStyleSup">292</span></a></p></span></span><span id="sec0370" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;5</span><span class="elsevierStyleSectionTitle" id="sect0370">Heart failure and sepsis</span><p id="par2235" class="elsevierStylePara elsevierViewall">Severe sepsis and septic shock are common in our hospitals&#46; They cause major haemodynamic changes&#44; and can affect contractility to the point that these conditions can be considered a special form of acute HF&#46;<a class="elsevierStyleCrossRef" href="#bib2560"><span class="elsevierStyleSup">313</span></a> The definition&#44; aetiological diagnosis and treatment of sepsis are outside the scope of this guideline&#46; In this section&#44; we will deal with sepsis as it relates to acute myocardial insufficiency&#46;</p><p id="par2240" class="elsevierStylePara elsevierViewall">In cardiovascular terms&#44; sepsis causes a combination of hypovolaemia&#44; decreased vascular tone&#44; myocardial depression and microcirculatory problems&#46;<a class="elsevierStyleCrossRefs" href="#bib2565"><span class="elsevierStyleSup">314&#44;315</span></a> Fluid therapy is still the first line treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib2560"><span class="elsevierStyleSup">313&#44;316&#8211;318</span></a> In HF patients&#44; however&#44; early use of vasopressors&#44; which are essential to restore haemodynamic stability&#44; is needed to prevent fluid overload&#46; Despite the controversy surrounding its use and potentially damaging effect on arrhythmia&#44; immunomodulation and metabolic rate&#44; norepinephrine continues to be the first choice therapy in sepsis&#46;<a class="elsevierStyleCrossRefs" href="#bib2560"><span class="elsevierStyleSup">313&#8211;315</span></a></p><p id="par2245" class="elsevierStylePara elsevierViewall">Adrenaline should only be used when an additional drug is needed to maintain perfusion pressure&#44; and vasopressin&#44; which should not be used as first line treatment&#44; can be used in combination with adrenaline to down-dose vasoconstrictors&#46;<a class="elsevierStyleCrossRef" href="#bib2560"><span class="elsevierStyleSup">313</span></a> Dopamine may only be used as an alternative therapy in certain patients with bradycardia and at low risk for arrhythmia&#46; Phenylephrine should only be used when norepinephrine causes arrhythmia&#46;</p><p id="par2250" class="elsevierStylePara elsevierViewall">Dobutamine to improve contractility must be given in doses of up to 20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min when adequate cardiac output has not been achieved&#46;<a class="elsevierStyleCrossRefs" href="#bib2565"><span class="elsevierStyleSup">314&#44;315&#44;319&#8211;322</span></a></p><p id="par2255" class="elsevierStylePara elsevierViewall">Although vasodilators are&#44; in theory&#44; justified in sepsis&#44;<a class="elsevierStyleCrossRef" href="#bib2610"><span class="elsevierStyleSup">323</span></a> their use is not discussed in goal-directed guidelines&#46; IV administration is needed to correct hypovolaemia&#44; increase perfusion pressure and improve contractility&#46;</p><p id="par2260" class="elsevierStylePara elsevierViewall">Calcium sensitisers are not included in the latest Surviving Sepsis Campaign guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib2560"><span class="elsevierStyleSup">313</span></a> Although their use in sepsis patients has been explored in both clinical and experimental studies&#44;<a class="elsevierStyleCrossRefs" href="#bib2615"><span class="elsevierStyleSup">324&#8211;331</span></a> evidence is sparse&#44; and they should only be used when needed&#46;</p></span><span id="sec0375" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;6</span><span class="elsevierStyleSectionTitle" id="sect0375">Heart failure and renal replacement therapy</span><p id="par2265" class="elsevierStylePara elsevierViewall">Most &#40;90&#37;&#41; HF patients are admitted to hospital due to volume overload&#46;<a class="elsevierStyleCrossRef" href="#bib1175"><span class="elsevierStyleSup">36</span></a> In HF patients with anasarca&#44; the first priority must be to extract excess fluid&#46; IV loop diuretics significantly increase urine output and natriuresis to alleviate initial symptoms of dyspnoea and oedema&#44; but they become less effective with each new administration&#46; In addition&#44; loop diuretics are not without their side effects&#44; which include neurohormonal alternations and electrolyte imbalance&#46; In these cases&#44; a valid and increasingly popular alternative is renal replacement&#46; Several studies have shown that ultrafiltration is a safe method of reducing volume overload&#46; During extracorporeal ultrafiltration&#44; preload is maintained by drawing interstitial fluid into the intravascular space&#46; Ventricular filling pressures are reduced by reducing the amount of extravascular lung water&#46; The normalisation of pulmonary function improve cardiac function&#44; reduces the cardiac silhouette and optimises the restrictive haemodynamic pattern&#46;<a class="elsevierStyleCrossRef" href="#bib2655"><span class="elsevierStyleSup">332</span></a></p><p id="par2270" class="elsevierStylePara elsevierViewall">It is important to consider whether renal replacement techniques affect the action of medication given to treat congestive HF&#46; Some studies have reported variations in plasma antimicrobial levels in dialysed patients and the need to up-dose to ensure effectiveness&#44; but little information is available on the drugs used to treat HF&#46;<a class="elsevierStyleCrossRef" href="#bib2660"><span class="elsevierStyleSup">333</span></a></p><p id="par2275" class="elsevierStylePara elsevierViewall">Digoxin is not dialyzable&#44; therefore dosage must be adjusted to a glomerular filtration rate of less than 10<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46; Amiodarone&#44; however&#44; needs no dosage adjustment during dialysis&#46; The action of 5&#8211;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min dopamine and dobutamine is not affected by continuous haemofiltration&#44; and does not need to be adjusted during renal replacement&#46;<a class="elsevierStyleCrossRefs" href="#bib2665"><span class="elsevierStyleSup">334&#44;335</span></a></p><p id="par2280" class="elsevierStylePara elsevierViewall">Norepinephrine and adrenaline lose 0&#46;1&#37; of their administered dose during renal replacement&#46; Since this loss is insignificant&#44; dosage adjustment is unnecessary&#44; and this extracorporeal filtration has not been shown to affect the patient&#39;s haemodynamic status&#46;<a class="elsevierStyleCrossRefs" href="#bib2665"><span class="elsevierStyleSup">334&#44;335</span></a></p><p id="par2285" class="elsevierStylePara elsevierViewall">In the case of Milrinone&#44; half-life is extended during renal replacement&#44; and dosage must be adjusted accordingly&#46;<a class="elsevierStyleCrossRef" href="#bib2675"><span class="elsevierStyleSup">336</span></a></p><p id="par2290" class="elsevierStylePara elsevierViewall">The pharmacokinetics of levosimendan in patients with mild to moderate kidney failure is similar to its action in healthy individuals&#46; The effect of haemodialysis on the pharmacokinetics of levosimendan has not been determined&#44; and the action of its active metabolite in kidney failure has not been investigated&#46; Therefore&#44; levosimendan should be used with caution in these patients&#46; Clearance is approximately 3&#46;0<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;kg&#44; and it has a half-life of around one hour&#59; 54&#37; of the dose is excreted in urine and 44&#37; in the faeces&#46; Over 95&#37; of the administered dose is excreted in one week&#46; Trace amounts &#40;&#60;0&#46;05&#37;&#41; are excreted unchanged in urine&#46; Circulating OR-1855 and OR-1896 metabolites are slow to form and eliminate&#46; Levosimendan should not be used in severe renal impairment with creatinine clearance &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;<a class="elsevierStyleCrossRef" href="#bib2500"><span class="elsevierStyleSup">301</span></a></p></span><span id="sec0380" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;7</span><span class="elsevierStyleSectionTitle" id="sect0380">Mechanical ventilation in heart failure patients</span><p id="par2295" class="elsevierStylePara elsevierViewall">Respiratory failure due to decompensated CHF is usually treated with diuretics and oxygentherapy&#46; However&#44; surgical patients often need invasive or nonsustained ventilatory support&#44; although current trends prioritise non-invasive ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib2680"><span class="elsevierStyleSup">337</span></a></p><p id="par2300" class="elsevierStylePara elsevierViewall">In this context&#44; the need for mechanical ventilation can vary greatly&#46; For example&#44; in patients with acute coronary syndrome undergoing percutaneous coronary intervention&#44; mechanical ventilation is usually used when complications occur&#46; These&#44; in order of importance&#44; are cardiac arrest&#44; acute pulmonary oedema and cardiogenic shock&#46; The mortality rate in these patients is as high as 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib2685"><span class="elsevierStyleSup">338</span></a> Mechanical ventilation is among the interventions associated with the highest mortality rates in coronary care units&#44; relative to the patient&#39;s underlying pathology&#44;<a class="elsevierStyleCrossRef" href="#bib2690"><span class="elsevierStyleSup">339</span></a> although mortality associated with mechanical ventilation in intensive care units has decreased in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib2695"><span class="elsevierStyleSup">340</span></a></p><p id="par2305" class="elsevierStylePara elsevierViewall">Patients with deteriorated heart failure usually present hypoxia&#44; increased work of breathing&#44; increased oxygen uptake&#44; and decreased cardiac output&#46; Mechanical ventilation facilitates the work of breathing and of the heart&#44; and improves oxygen uptake&#46;</p><span id="sec0385" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;7&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0385">Effect of mechanical ventilation on haemodynamics in patients with acute pulmonary oedema</span><p id="par2310" class="elsevierStylePara elsevierViewall">Patients with deteriorated heart failure usually present hypoxia&#44; increased work of breathing&#44; increased oxygen uptake&#44; and decreased cardiac output&#46; Mechanical ventilation can have a positive effect on all these symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib2700"><span class="elsevierStyleSup">341&#8211;343</span></a></p><p id="par2315" class="elsevierStylePara elsevierViewall">In conclusion&#44; in patients with a health heart&#44; mechanical ventilation can reduce venous return&#44; and consequently&#44; cardiac output&#46; In patients with significant heart failure and increased preload&#44; increasing intrathoracic pressure can improve ventricular function&#44; and consequently&#44; cardiac output&#46;</p></span><span id="sec0390" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;7&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0390">The role of PEEP</span><p id="par2320" class="elsevierStylePara elsevierViewall">On the subject of mechanical ventilation&#44; the increase in intrathoracic pressure induced by PEEP can improve heart function in HF patients&#44; albeit at the expense of reducing pre- and afterload&#46; PEEP can also help improve pulmonary gas exchange&#44; albeit at the expense of the resulting alveolar recruitment and subsequently of the gas exchange surface&#59; this leads to a reduction in intrapulmonary shunt&#46;<a class="elsevierStyleCrossRefs" href="#bib2700"><span class="elsevierStyleSup">341&#44;344</span></a></p></span><span id="sec0395" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;7&#46;3</span><span class="elsevierStyleSectionTitle" id="sect0395">Weaning from mechanical ventilation</span><p id="par2325" class="elsevierStylePara elsevierViewall">The change from positive to negative intrathoracic pressure has a number of pathophysiological consequences&#46; It poses no problem in most patients&#44; because the cause of the pulmonary oedema has been resolved &#40;arrhythmia&#44; ischaemia&#44; hypertensive crisis&#44; etc&#46;&#41;&#44; and appropriate treatment can also resolve low cardiac output&#46;</p><p id="par2330" class="elsevierStylePara elsevierViewall">In some patients&#44; however&#44; weaning from mechanical ventilation is particularly difficult&#58;<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">a&#46;</span><p id="par2335" class="elsevierStylePara elsevierViewall">Patients with significantly depressed heart function&#58; Weaning from mechanical ventilation associated with a heart problem is often unsuccessful in patients with depressed heart function&#46; These patients are unable to respond to the haemodynamic changes of spontaneous breathing&#44; due to increased venous return and increased work of breathing&#46; In this situation&#44; weaning must be done gradually while continuing cardiovascular support medication&#46; Diuretics&#44; inotropes and vasodilators are indicated during weaning due to excessive preload&#44; increased afterload or associated myocardial ischaemia&#46;<a class="elsevierStyleCrossRef" href="#bib2720"><span class="elsevierStyleSup">345</span></a> In addition&#44; ventilatory modes &#40;with PEEP&#41; that facilitate a gradual return to spontaneous breathing should be used&#46; Non-invasive ventilation is important in this clinical situation&#46; Studies are currently exploring predictive factors for weaning failure&#44; in which BNP could be predictor for failure following cardiac surgery&#46;<a class="elsevierStyleCrossRef" href="#bib2725"><span class="elsevierStyleSup">346</span></a></p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">b&#46;</span><p id="par2340" class="elsevierStylePara elsevierViewall">Patients with severe left ventricular dysfunction and comorbid COPD&#58; In this situation&#44; weaning from mechanical ventilation can cause a new pulmonary oedema that would prevent withdrawal of ventilatory support&#46; There are a number of factors leading to onset of cardiogenic pulmonary oedema<a class="elsevierStyleCrossRef" href="#bib2730"><span class="elsevierStyleSup">347</span></a>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">b&#46;1&#46;</span><p id="par2345" class="elsevierStylePara elsevierViewall">Change from positive to negative intrathoracic pressure&#58; This&#44; as mentioned above&#44; increases venous return&#46; In COPD patients&#44; however&#44; this can have major implications since these patients already have a certain amount of autoPEEP &#40;auto-positive end expiratory pressure&#41;&#44; and therefore need much greater negative pressure to achieve adequate tidal volume&#46; The greater the negative intrathoracic pressure&#44; the greater the venous return&#44; and subsequently&#44; preload&#46; Negative pressure&#44; meanwhile&#44; is associated with an increase in afterload&#44; which is in turn associated with an increase in left ventricular transmural pressure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">b&#46;2&#46;</span><p id="par2350" class="elsevierStylePara elsevierViewall">Activation of the sympathetic nervous system&#58; This increases venous tone and subsequently the volume of blood returning to the heart&#44; in other words&#44; preload&#46; It also increases systolic arterial pressure at the expense of an increase in arteriolar resistance&#44; which evidently increases afterload&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0370"><p id="par2355" class="elsevierStylePara elsevierViewall">Both these factors contribute to the failing heart receiving a significant volume of blood which it cannot fully eject&#44; thus increasing the risk of a new episode of acute pulmonary oedema&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">b&#46;3&#46;</span><p id="par2360" class="elsevierStylePara elsevierViewall">Ventricular interdependence&#58; Right ventricular dilation due to increased venous return and increased pulmonary vascular resistance causes the intraventricular septum to shift to the left&#44; thus increasing left ventricular end diastolic pressure&#44; in other words&#44; it increases afterload and reduces left ventricular end diastolic volume&#46; This in turn reduces cardiac output&#46;<a class="elsevierStyleCrossRef" href="#bib2735"><span class="elsevierStyleSup">348</span></a></p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">b&#46;4&#46;</span><p id="par2365" class="elsevierStylePara elsevierViewall">Increased pulmonary volume&#58; Can compress left-side cavities due to dynamic hyperinflation caused by airway obstruction in COPD patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">b&#46;5&#46;</span><p id="par2370" class="elsevierStylePara elsevierViewall">Risk of myocardial ischaemia&#58; Associated with changes in the ventilation&#47;perfusion ratio with associated hypoxaemia&#44;<a class="elsevierStyleCrossRef" href="#bib2740"><span class="elsevierStyleSup">349</span></a> sympathetic activation caused by weaning&#44; and the increased systolic effort of the left ventricle to meet the demand of increased O<span class="elsevierStyleInf">2</span> consumption&#46;</p></li></ul></p><p id="par2375" class="elsevierStylePara elsevierViewall">In consideration of all the above&#44; it is important to focus treatment on reducing venous return&#44; and furosemide has been shown to prevent pulmonary oedema in most patients&#44;<a class="elsevierStyleCrossRef" href="#bib2730"><span class="elsevierStyleSup">347</span></a> improve cardiac contractility and reduce afterload&#44; thus enabling the failing heart to handle the overload caused by weaning in these special situations&#46;</p></span><span id="sec0400" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6&#46;7&#46;4</span><span class="elsevierStyleSectionTitle" id="sect0400">Non-invasive ventilation in CHF patients</span><p id="par2380" class="elsevierStylePara elsevierViewall">Non-invasive ventilation &#40;NIV&#41; avoids the drawbacks of endotrachael intubation and also improves both oxygenation and the associated metabolic changes&#46;</p><p id="par2385" class="elsevierStylePara elsevierViewall">There is ample evidence that NIV increases PO<span class="elsevierStyleInf">2</span> compared with patients ventilated through nasal prongs&#46; It also reduces the need for endotrachael intubation in this patient group&#46;<a class="elsevierStyleCrossRef" href="#bib2745"><span class="elsevierStyleSup">350</span></a> In addition to increased PO<span class="elsevierStyleInf">2</span> and improved metabolism&#44; some studies have shown a decreased mortality in NIV patients&#46;<a class="elsevierStyleCrossRefs" href="#bib2750"><span class="elsevierStyleSup">351&#44;352</span></a> In a more recent study&#44; however&#44; Gray et al&#46; found no relationship with mortality&#44; and recommended that CPAP or NIV be considered as adjuvant therapy in patients with acute severe cardiogenic pulmonary oedema in the presence of severe breathing difficulty or lack of progress with drug therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib2760"><span class="elsevierStyleSup">353&#8211;355</span></a></p><p id="par2390" class="elsevierStylePara elsevierViewall">NIV reduces the work of breathing&#44; at the expense of breathing rate and respiratory muscle effort&#44;<a class="elsevierStyleCrossRef" href="#bib2775"><span class="elsevierStyleSup">356</span></a> and neither CPAP nor Bi Pap are associated with an increase in cardiac ischaemic events&#46;<a class="elsevierStyleCrossRef" href="#bib2780"><span class="elsevierStyleSup">357</span></a></p></span></span></span><span id="sec0405" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">7</span><span class="elsevierStyleSectionTitle" id="sect0405">Conclusions&#46; Main strengths and weakness of the evidence</span><p id="par2395" class="elsevierStylePara elsevierViewall">HF should not be a contraindication for noncardiac surgical interventions that would reasonably increase life expectancy or improve quality of life&#59; however&#44; it is a predictor of poor prognosis in this patient group&#46;</p><p id="par2400" class="elsevierStylePara elsevierViewall">There is Strong evidence to recommend that patients with systolic heart failure scheduled for intermediate- to high-risk surgery are treated in hospitals with ample experience in this field&#44; with the capacity to undertake an appropriate preoperative evaluation&#44; and with an intensive care unit equipped for the postoperative care of these patients&#46;</p><p id="par2405" class="elsevierStylePara elsevierViewall">There is Strong evidence that systolic HF has a poorer prognosis than diastolic HF in intermediate- to high-risk surgery&#46;</p><p id="par2410" class="elsevierStylePara elsevierViewall">There is Strong evidence that the risk of HF patients depends on the condition of their heart and the type of surgery scheduled&#46;</p><p id="par2415" class="elsevierStylePara elsevierViewall">There is strong evidence that elective surgery should always be performed in stable patients that are responding well to treatment&#46;</p><p id="par2420" class="elsevierStylePara elsevierViewall">There is evidence that the patient&#39;s background medication should be continued until the day of surgery&#44; and restarted as soon as possible&#46;</p><p id="par2425" class="elsevierStylePara elsevierViewall">Although some studies have recently rekindled the controversy surrounding continuation of beta-blockers in surgical patients&#44; we consider that there is no strong evidence to recommend their withdrawal in these patients&#46;</p><p id="par2430" class="elsevierStylePara elsevierViewall">There is no strong evidence that epidural&#47;spinal anaesthesia is better than general anaesthesia&#46;</p><p id="par2435" class="elsevierStylePara elsevierViewall">There is reasonable evidence that&#44; spinal anaesthesia can cause severe&#44; difficult-to-reverse haemodynamic deterioration in severe aortic stenosis&#46; Although there are no studies to confirm that this technique should be contraindicated&#44; we believe it should be performed with the utmost caution&#46;</p><p id="par2440" class="elsevierStylePara elsevierViewall">There is strong evidence that volatile anaesthetics&#44; mainly sevofluorane&#44; have a clear cardioprotective action&#46; However&#44; there is no solid evidence that they reduce mortality in these patients&#46;</p><p id="par2445" class="elsevierStylePara elsevierViewall">There is strong evidence that levosimendan has a clear preconditioning action&#44; and subsequently&#44; a cardioprotective action&#46; However&#44; few studies have been conducted in this patient group&#46;</p><p id="par2450" class="elsevierStylePara elsevierViewall">There is evidence that adequate postoperative analgesia reduces morbidity in this patient group&#44; but there is no strong evidence of its impact on mortality&#46;</p></span><span id="sec0410" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">8</span><span class="elsevierStyleSectionTitle" id="sect0410">Methodology for formulating recommendations</span><p id="par2455" class="elsevierStylePara elsevierViewall">Wherever a high Level of Evidence with a strong Grade of Recommendation &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 1</a>&#41; was found in the literature&#44; the authors and reviewers considered the evidence to be strong enough to make a recommendation&#46;</p><p id="par2460" class="elsevierStylePara elsevierViewall">Wherever insufficient evidence was found<a class="elsevierStyleCrossRefs" href="#bib2785"><span class="elsevierStyleSup">358&#8211;362</span></a>&#44; we turned to scientific data and expert opinion&#44; using the modified Delphi method&#46;<a class="elsevierStyleCrossRefs" href="#bib2810"><span class="elsevierStyleSup">363&#44;364</span></a></p><p id="par2465" class="elsevierStylePara elsevierViewall">The Delphi method assumes that there are several fields of health science areas where scientific information does not provide sufficiently strong evidence on which to base decisions&#46; These knowledge gaps&#44; therefore&#44; must be filled from other sources of knowledge that stem more from practical experience&#44; and for this purpose the opinion of a group of experts is evaluated&#46; The evaluation process must be systematic and able to withstand scientific assessment&#46;</p></span><span id="sec0415" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">9</span><span class="elsevierStyleSectionTitle" id="sect0415">Factors facilitating and limiting implementation of these guidelines</span><span id="sec0420" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">9&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0420">Facilitating factors</span><p id="par2470" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8226;</span><p id="par2475" class="elsevierStylePara elsevierViewall">HF patients are clearly identified in practically all hospitals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8226;</span><p id="par2480" class="elsevierStylePara elsevierViewall">HF patients are usually receiving excellent treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8226;</span><p id="par2485" class="elsevierStylePara elsevierViewall">Some hospital are equipped with Cardiac Care Units&#44; where noncardiac surgery in these patients is a common occurrence&#44; and the attending physicians are highly experienced&#46;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8226;</span><p id="par2490" class="elsevierStylePara elsevierViewall">Protocolised preoperative evaluation in these patients is simple and does not place an extra burden on hospital resources&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8226;</span><p id="par2495" class="elsevierStylePara elsevierViewall">No additional budget is needed to follow these guidelines&#46;</p></li></ul></p></span><span id="sec0425" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">9&#46;2</span><span class="elsevierStyleSectionTitle" id="sect0425">Limiting factors</span><p id="par2500" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8226;</span><p id="par2505" class="elsevierStylePara elsevierViewall">Medical staff often underestimates the seriousness of diastolic HF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">&#8226;</span><p id="par2510" class="elsevierStylePara elsevierViewall">HF is often confused with ischaemic heart disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">&#8226;</span><p id="par2515" class="elsevierStylePara elsevierViewall">There is ample information in the literature and evidence on noncardiac surgery in patients with ischaemic heart disease&#44; but far less on noncardiac surgery in HF patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">&#8226;</span><p id="par2520" class="elsevierStylePara elsevierViewall">Systolic HF patients cannot always be transferred to hospitals with experience in this disease&#59; therefore&#44; surgery is sometimes performed in less experienced hospitals&#44; where protocolisation is limited and outcomes are poorer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par2525" class="elsevierStylePara elsevierViewall">Preoperative preconditioning with levosimendan requires patients to be admitted some hours before their surgery so that the treatment can be performed in a unit with monitoring equipment&#46; This could have an impact on bed management in these units&#46;</p></li></ul></p></span></span><span id="sec0430" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">10</span><span class="elsevierStyleSectionTitle" id="sect0430">Economic impact of this CPG</span><p id="par2530" class="elsevierStylePara elsevierViewall">Implementation of most of these guidelines does not&#44; a priori&#44; entail addition cost&#46;</p><p id="par2535" class="elsevierStylePara elsevierViewall">The only costly recommendation is the use of preconditioning with levosimendan&#46; This&#44; as mentioned above&#44; calls for early admission to monitoring unit&#44; to which must be added the cost of the drug&#46;</p><p id="par2540" class="elsevierStylePara elsevierViewall">No studies have as yet analysed the cost&#47;benefit ratio of levosimendan in this indication&#44; although similar studies have been carried out in non-surgical patients&#46;</p></span><span id="sec0435" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">11</span><span class="elsevierStyleSectionTitle" id="sect0435">Updating these guidelines</span><p id="par2545" class="elsevierStylePara elsevierViewall">Medical information is known to grow exponentially&#46; In the 2013 PubMed database alone there are 3529 studies with the term &#8220;heart failure&#8221; in the title&#44; and a further 358 with the term &#8220;cardiac failure&#8221;&#46;</p><p id="par2550" class="elsevierStylePara elsevierViewall">Evidence considered Strong today can tomorrow be modified on the basis of new findings&#46; However&#44; large organisations cannot publish new guidelines each year&#44; or even every two years&#46; Ideally&#44; guidelines should be reviewed every 4&#8211;5 years&#46; Considering that a guideline of these characteristics takes over 12 months to draft&#44; every 3 or 4 years the task force&#44; sponsored by SEDAR&#44; will be reconvened to review these recommendations on the basis of this CPG&#46;</p><p id="par2555" class="elsevierStylePara elsevierViewall">Ideally&#44; if any documents that would have a substantial impact on the prognosis of this patient group should emerge at any time before each scheduled review&#44; the SEDAR and the task force will make them known to all association members&#46;</p></span><span id="sec0440" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0440">Sponsor</span><p id="par2560" class="elsevierStylePara elsevierViewall">This CPG has been sponsored by donation from &#8220;Orion Pharma&#8221; to the Spanish Society of Anaesthesiology&#44; Critical Care and Pain Management &#40;SEDAR&#41; to facilitate publication of this CPG&#46;</p><p id="par2565" class="elsevierStylePara elsevierViewall">The sponsor did not select the editors and reviewers involved in drafting this guideline&#46; Editors and reviewers were selected by the coordinating body&#46; The sponsor did not provide the task force with any kind of documentation or studies&#46; The sponsor did not take part in task force meetings&#46;</p></span><span id="sec0445" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0445">Conflict of interests</span><p id="par2570" class="elsevierStylePara elsevierViewall">All members of the Working Group and those who participated in the external review&#46;<ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0440"><p id="par2575" class="elsevierStylePara elsevierViewall">Alvarez Juli&#225;n&#58; Received fees from Abbott and Orion Pharma for speaking at conferences&#46; Received Clinical and Experimental Research grants from Grunenthal and Orion Pharma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><p id="par2580" class="elsevierStylePara elsevierViewall">Baluja Aurora&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0450"><p id="par2585" class="elsevierStylePara elsevierViewall">Calvo Vecino Jos&#233; Mar&#237;a&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0455"><p id="par2590" class="elsevierStylePara elsevierViewall">Cabadas Rafael&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0460"><p id="par2595" class="elsevierStylePara elsevierViewall">Cari&#241;ena Agust&#237;n&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0465"><p id="par2600" class="elsevierStylePara elsevierViewall">Garc&#237;a Rafael&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0470"><p id="par2605" class="elsevierStylePara elsevierViewall">Gilsanz Fernando&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0475"><p id="par2610" class="elsevierStylePara elsevierViewall">Gonz&#225;lez-Juanatey Jose Ram&#243;n&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0480"><p id="par2615" class="elsevierStylePara elsevierViewall">Gonzalez Ana&#58; Received fees from Orion Pharma&#46; Participated in training programmes organised by Orion Pharma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><p id="par2620" class="elsevierStylePara elsevierViewall">Mart&#237;n Trapero Carlos&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0490"><p id="par2625" class="elsevierStylePara elsevierViewall">Mu&#241;oz Aguilera Roberto&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0495"><p id="par2630" class="elsevierStylePara elsevierViewall">Mu&#241;oz Pedro&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0500"><p id="par2635" class="elsevierStylePara elsevierViewall">Ortega Urbaneja Montserrat&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0505"><p id="par2640" class="elsevierStylePara elsevierViewall">Solera Jorge&#58; None</p></li><li class="elsevierStyleListItem" id="lsti0510"><p id="par2645" class="elsevierStylePara elsevierViewall">Veiras Sonia&#58; None</p></li></ul></p></span></span>"
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            4 => array:3 [
              "identificador" => "sec0260"
              "titulo" => "Postoperative risk reduction strategy"
              "secciones" => array:3 [
                0 => array:2 [ …2]
                1 => array:2 [ …2]
                2 => array:3 [ …3]
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        6 => array:3 [
          "identificador" => "sec0305"
          "titulo" => "Specific pathologies in heart failure patients"
          "secciones" => array:7 [
            0 => array:3 [
              "identificador" => "sec0310"
              "titulo" => "Valve disease"
              "secciones" => array:3 [
                0 => array:2 [ …2]
                1 => array:2 [ …2]
                2 => array:2 [ …2]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0330"
              "titulo" => "Hypertension"
            ]
            2 => array:3 [
              "identificador" => "sec0335"
              "titulo" => "Patients with right ventricular failure&#46; Right-sided heart failure"
              "secciones" => array:1 [
                0 => array:2 [ …2]
              ]
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            3 => array:3 [
              "identificador" => "sec0345"
              "titulo" => "Pulmonary arterial hypertension"
              "secciones" => array:4 [
                0 => array:2 [ …2]
                1 => array:2 [ …2]
                2 => array:2 [ …2]
                3 => array:2 [ …2]
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            4 => array:2 [
              "identificador" => "sec0370"
              "titulo" => "Heart failure and sepsis"
            ]
            5 => array:2 [
              "identificador" => "sec0375"
              "titulo" => "Heart failure and renal replacement therapy"
            ]
            6 => array:3 [
              "identificador" => "sec0380"
              "titulo" => "Mechanical ventilation in heart failure patients"
              "secciones" => array:4 [
                0 => array:2 [ …2]
                1 => array:2 [ …2]
                2 => array:2 [ …2]
                3 => array:2 [ …2]
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        7 => array:2 [
          "identificador" => "sec0405"
          "titulo" => "Conclusions&#46; Main strengths and weakness of the evidence"
        ]
        8 => array:2 [
          "identificador" => "sec0410"
          "titulo" => "Methodology for formulating recommendations"
        ]
        9 => array:3 [
          "identificador" => "sec0415"
          "titulo" => "Factors facilitating and limiting implementation of these guidelines"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0420"
              "titulo" => "Facilitating factors"
            ]
            1 => array:2 [
              "identificador" => "sec0425"
              "titulo" => "Limiting factors"
            ]
          ]
        ]
        10 => array:2 [
          "identificador" => "sec0430"
          "titulo" => "Economic impact of this CPG"
        ]
        11 => array:2 [
          "identificador" => "sec0435"
          "titulo" => "Updating these guidelines"
        ]
        12 => array:2 [
          "identificador" => "sec0440"
          "titulo" => "Sponsor"
        ]
        13 => array:2 [
          "identificador" => "sec0445"
          "titulo" => "Conflict of interests"
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        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-04-30"
    "fechaAceptado" => "2015-05-04"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Clinical Practice Guideline<span class="elsevierStyleVsp" style="height:1.5px"></span>Promoted by&#58; SEDAR<span class="elsevierStyleVsp" style="height:1.5px"></span>Spanish Society of Anesthesiology&#44; Critical Care and Pain Therapy&#46;</p>"
      ]
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    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:2 [
          0 => array:4 [
            "etiqueta" => "Annex 1"
            "titulo" => "Literature search"
            "identificador" => "sec0455"
            "apendiceSeccion" => array:2 [
              0 => array:3 [
                "apendice" => "<p id="par2655" class="elsevierStylePara elsevierViewall">&#40;&#40;&#40;&#40;&#40;&#40;&#8220;perioperative care&#8221;&#91;MeSH Terms&#93; AND &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;heart failure&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;heart&#8221;&#91;All Fields&#93; AND &#8220;failure&#8221;&#91;All Fields&#93;&#41; OR &#8220;heart failure&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#8221;&#91;MeSH Terms&#93; OR &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41; AND &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41; OR &#40;&#8220;Intraoperative Complications&#8221;&#91;Mesh&#93; AND &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41;</p> <p id="par2660" class="elsevierStylePara elsevierViewall">&#40;&#40;&#40;&#40;&#40;&#40;&#8220;perioperative care&#8221;&#91;MeSH Terms&#93; AND &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;heart failure&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;heart&#8221;&#91;All Fields&#93; AND &#8220;failure&#8221;&#91;All Fields&#93;&#41; OR &#8220;heart failure&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#8221;&#91;MeSH Terms&#93; OR &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41; AND &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41; OR &#40;&#8220;Intraoperative Complications&#8221;&#91;Mesh&#93; AND &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41; AND &#40;&#8220;humans&#8221;&#91;MeSH Terms&#93; AND &#40;English&#91;lang&#93; OR Spanish&#91;lang&#93;&#41; AND &#8220;adult&#8221;&#91;MeSH Terms&#93;&#41;</p> <p id="par2665" class="elsevierStylePara elsevierViewall">&#40;&#40;&#40;&#40;&#40;&#40;&#8220;perioperative care&#8221;&#91;MeSH Terms&#93; AND &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;heart failure&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;heart&#8221;&#91;All Fields&#93; AND &#8220;failure&#8221;&#91;All Fields&#93;&#41; OR &#8220;heart failure&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;anaesthesia&#8221;&#91;All Fields&#93; OR &#8220;anesthesia&#8221;&#91;MeSH Terms&#93; OR &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41;&#41; OR &#8220;Heart failure treatment&#8221;&#91;All Fields&#93;&#41; OR &#40;&#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41; AND &#8220;anesthesia&#8221;&#91;All Fields&#93;&#41;&#41; OR &#40;&#8220;Intraoperative Complications&#8221;&#91;Mesh&#93; AND &#40;&#8220;Heart Diseases&#8221;&#91;Mesh&#93; AND &#8220;Heart Valve Diseases&#8221;&#91;Mesh&#93; AND &#8220;Hypertension&#44; Pulmonary&#8221;&#91;Mesh&#93;&#41;&#41; AND &#40;&#40;Clinical Trial &#91;ptyp&#93; OR Review&#91;ptyp&#93; OR Meta-Analysis&#91;ptyp&#93; OR systematic&#91;sb&#93;&#41; AND &#8220;humans&#8221;&#91;MeSH Terms&#93; AND &#40;English&#91;lang&#93; OR Spanish&#91;lang&#93;&#41; AND &#8220;adult&#8221;&#91;MeSH Terms&#93;&#41;</p> <p id="par2670" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleInlineFigure"><elsevierMultimedia class="elsevierStyleLink" ident="fx1"></elsevierMultimedia></span></p>"
                "titulo" => "&#42;&#42;Refined search"
                "identificador" => "sec0460"
              ]
              1 => array:3 [
                "apendice" => "<p id="par2675" class="elsevierStylePara elsevierViewall">&#8220;perioperative heart failure&#8221;&#91;All Fields&#93; OR &#8220;heart failure&#8221; AND &#40;&#8220;therapy&#8221;&#91;Subheading&#93; OR &#8220;therapy&#8221;&#91;All Fields&#93; OR &#8220;treatment&#8221;&#91;All Fields&#93; OR &#8220;therapeutics&#8221;&#91;MeSH Terms&#93;&#41; OR &#40;&#40;&#8220;heart failure&#8221;&#91;MeSH Terms&#93; OR &#40;&#8220;heart&#8221;&#91;All Fields&#93; AND &#8220;failure&#8221;&#91;All Fields&#93;&#41; OR &#8220;heart failure&#8221;&#91;All Fields&#93;&#41; AND &#40;&#8220;haemodynamic&#8221;&#91;All Fields&#93; OR &#8220;hemodynamics&#8221;&#91;MeSH Terms&#93; OR &#8220;hemodynamics&#8221;&#91;All Fields&#93; OR &#8220;hemodynamic&#8221;&#91;All Fields&#93;&#41;&#41; OR &#8220;Heart Failure&#8221;&#91;Majr&#93; OR &#40;&#40;&#8220;Heart failure&#8221;&#91;All Fields&#93; AND &#8220;Anesthesia&#44; General&#8221;&#91;MAJR&#93;&#41; OR &#8220;Intraoperative Care&#8221;&#91;MeSH Terms&#93;&#41; OR &#8220;Preoperative Care&#8221;&#91;MAJR&#93; AND &#40;&#40;Meta-Analysis&#91;ptyp&#93; OR Review&#91;ptyp&#93; OR Clinical Trial&#91;ptyp&#93; OR systematic&#91;sb&#93;&#41; AND &#8220;last 5 years&#8221;&#91;PDat&#93; AND Humans&#91;Mesh&#93; AND &#40;English&#91;lang&#93; OR Spanish&#91;lang&#93;&#41; AND adult&#91;MeSH&#93;</p>"
                "titulo" => "&#42;Extended search"
                "identificador" => "sec0465"
              ]
            ]
          ]
          1 => array:4 [
            "apendice" => "<p id="par2685" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0475"
          ]
        ]
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Risk reduction strategy that we use in these recommendations&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm heart failure&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Example of hemodynamic optimization &#40;Cl<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cardiac index&#59; SVV<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>stroke volume vaiation&#59; SVI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>stroke volume index&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mechanism of preaconditioning &#40;LVEF<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>left ventricular ejection fraction&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Treatment of postoperative acute heart failure&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Implications of strength of recommendation in the GRADE system</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Management&#47;planners&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Implications of a Strong recommendation</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">The great majority of individual would agree with the recommended strategy&#44; and only a small percentage would disagree&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most patients should receive the recommended intervention&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The recommendation can be adopted as a healthcare policy in most circumstances&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Implications of a weak recommendation</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Most individuals would agree with the recommended strategy&#44; but many will disagree&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Different options would be appropriate for different patients&#46; The doctor must help each patient reach the decision that most reflects their values and preferences&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Serious discussions with stakeholders are needed&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evidence rating and grades of recommendation&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:1 [
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Typical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">More specific symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dyspnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Elevated jugular venous pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Orthopnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatojugular reflux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Paroxysmal nocturnal dyspnoea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Third heart sound &#40;atrial gallop&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reduced exercise tolerance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heart murmur&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Less typical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less specific symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Wheezing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peripheral oedema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nocturnal cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pulmonary rales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Weight gain &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>kg&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diminished vesicular murmur&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Weight loss &#40;advanced disease&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tachycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Loss of appetite&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Irregular pulse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">PalpitationsSyncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tachypnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hepatomegaly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ascites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab944416.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Symptomatology of heart failure&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ACC&#47;AHA</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stage A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At high risk for HF but without structural heart disease or symptoms of HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Class 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No limitation of physical activity&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stage B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Structural heart disease but without signs or symptoms of HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Class II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Slight limitation of physical activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stage C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Structural heart disease with prior or current symptoms of HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Class III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Marked limitation of physical activity&#59; any activity causes symptoms of HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stage D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Advanced structural heart disease and marked symptoms of heart failure at rest refractory to the best medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Class IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Symptoms of HF at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab944443.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Functional classification according to the American College of Cardiology&#47;American heart Association &#40;ACC&#47;AHA&#41; and of the New York Heart Association &#40;NYHA&#41; based on severity of symptoms and exercise&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">According to NYHA functional class</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA III-IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Refractory HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Terminal HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diuretics &#43;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SpironolactoneEplerenone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ACE inhibitors&#47;ARBs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACE inhibitors&#47;ARBs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACE inhibitors and&#47;or ARBs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">B-blocker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B-blocker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B-blocker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mechanical devicesHeart transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab944433.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Management of systolic heart failure</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drug&#47;dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NYHA II with signs or symptoms of congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chlorthalidone 50&#8211;100<span class="elsevierStyleHsp" style=""></span>mg&#47;24&#8211;48<span class="elsevierStyleHsp" style=""></span>hFurosemide 20&#8211;40<span class="elsevierStyleHsp" style=""></span>mg&#47;dayTorasemide 10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>mg&#47;day240<span class="elsevierStyleHsp" style=""></span>mg&#47;day40<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Aldosterone receptor antagonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NYHA III-IV&#59; evaluate for class II with FE<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#37;Post-IAM HF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spironolactone 12&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dayEplerenone 25<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>mg&#47;day50<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ACE inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All patients unless contraindicated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enalapril 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dayCaptopril 6&#46;25&#8211;12&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;8&#8211;12<span class="elsevierStyleHsp" style=""></span>hFosinopril 10<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>hLisinopril 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>hPerindopril 2<span class="elsevierStyleHsp" style=""></span>mg&#47;dayQuinapril 5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>hRamipril 1&#46;25&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h1&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h &#40;severe HF&#41;Trandolipril 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>mg&#47;day50<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h40<span class="elsevierStyleHsp" style=""></span>mg&#47;day40<span class="elsevierStyleHsp" style=""></span>mg&#47;day4<span class="elsevierStyleHsp" style=""></span>mg&#47;day20<span class="elsevierStyleHsp" style=""></span>mg&#47;12h10<span class="elsevierStyleHsp" style=""></span>mg&#47;day5<span class="elsevierStyleHsp" style=""></span>mg&#47;day4<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ARBs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients intolerant to ACE inhibitorsAssociated with ACE inhibitors in patients with refractory symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Candesartan 4&#8211;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dayValsartan 40<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>hLosartan 12&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32<span class="elsevierStyleHsp" style=""></span>mg&#47;day320<span class="elsevierStyleHsp" style=""></span>mg&#47;day50&#8211;100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hydralazine&#47;isosorbide dinitrate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients intolerant to ACE inhibitors or ARBsPatients with symptoms despite ACE inhibitors&#44; ARBs&#44; betablockers and aldosterone antagonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydralazine 25<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>hIsosorbide dinitrate 40&#8211;60<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75<span class="elsevierStyleHsp" style=""></span>mg&#47;6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">B-blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All stable patients unless contraindicated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carvedilol 3&#46;125<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>hBisoprolol 1&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>hNebivolol 1&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h10<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h10<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Digoxin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NYHA class III&#8211;IV and maintain if worsens to IIAtrial fibrillationEnlarged ventricle and third heart sound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Digoxin 0&#46;125<span class="elsevierStyleHsp" style=""></span>0&#46;25<span class="elsevierStyleHsp" style=""></span>mg&#47;dayAdjust according to kidney function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab944424.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Pharmacological therapy indicated in the treatment of heart failure&#46;</p>"
        ]
      ]
      11 => array:7 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Low-risk&#46; Risk of cardiac complications &#60; 1&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dental surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eye surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Breast surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Minor orthopaedic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Minor genitourinary surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reconstructive surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Superficial surgical procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Day surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Endoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>X-ray studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Intermediate-risk&#46; Risk of cardiac complications 1-5&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abdominal surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thoracic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Carotid artery surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Head and neck surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prostate surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Endovascular embolization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Peripheral artery angioplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Major genitourinary surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Major orthopaedic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Brain surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lung&#44; liver and kidney transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">High-risk&#46; Risk of cardiac complications &#60; 5&#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aortic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Peripheral artery surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Surgical risk in CHF patients based on the type of surgery&#46;</p>"
        ]
      ]
      12 => array:7 [
        "identificador" => "tbl0040"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Low-risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Patients with no known heart disease and with &#8804; 2 cardiovascular risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Intermediate-risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No known heart disease and 2 cardiovascular risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High-risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">High-risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acute coronary syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arrhythmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptomatic valvular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complex congenital heart disease of pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cardiovascular risk factors&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Insulin-dependent diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kidney failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#62; 65 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stroke&#47;Transitory ischaemic attack &#40;TIA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab944430.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Surgical risk based preoperative cardiac status&#46;</p>"
        ]
      ]
      13 => array:7 [
        "identificador" => "tbl0045"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Unstable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure NYHA IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">One-month history of new onset or worsened congestive heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Significant arrhythmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleSup">rd</span> degree AV block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Significant ventricular arrhythmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Supraventicular arrhythmias including atrial fibrillation with rapid ventricular response&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptomatic bradycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Suspicion of prior ventricular tachycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Significant valvular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Significant aortic stenosis&#44; with mean gradient &#62; 40 mm Hg or valve area &#60; 1 cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptomatic mitral stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab944417.png"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Cardiological situation in which the patients must be evaluated using specific cardiological protocols&#46;</p>"
        ]
      ]
      14 => array:7 [
        "identificador" => "tbl0050"
        "etiqueta" => "Table 8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Optimised monitoring</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Invasive arterial pressure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Central venous pressure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">CO&#44; SV seen on arterial waveform</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Swan-Ganz catheter</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Transthoracic electrical impedance</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Partial CO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">rebreathing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Oesophageal Doppler</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Echocardiagraphy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:1.0px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">Parameters measured</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Static parameters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Pressures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Central venous pressure &#40;CVP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Pulmonary wedge pressure &#40;PWP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Volumes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Right ventriclular end-diastolic pressure index &#40;RVEDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Left ventriclular end-diastolic pressure index &#40;LVEDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; End-diastolic volume index &#40;EDVI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Intrathoracic total blood volume index &#40;ITBI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; <span class="elsevierStyleItalic">Dynamic parameters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Venous saturation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; SvO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; SvO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Heart lung interaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Perfusion pressure variation &#40;PPV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Systolic pressure variation &#40;SPV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Systolic volume variation &#40;SVV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Recommended monitoring in patients undergoing preoperative haemodynamic optimisation with inotropic drugs such as levosimendan&#46;</p>"
        ]
      ]
      15 => array:7 [
        "identificador" => "tbl0055"
        "etiqueta" => "Table 9"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">1&#46; Diminished preload</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Hypovolaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; PEEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Cardiac tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Pneumothorax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">2&#46; Increased afterload</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Vasoconstriction&#58; hypothermia&#59; sympathetic stimulation&#59; poorly controlled hypetension&#59; pain&#59; administration of alpha mimetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Inadequately controlled obstructive hypertrophic cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Uncontrolled aortic stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prosthetic malfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">3&#46; Diminished contractility</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Preoperative ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Myocardial oedema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Myocardial ischaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Hypoxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Severe acidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Overdose of beta-blockers or other antiarrhythmics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">4&#46; Alterations in heart rate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Bradycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8226; Tachycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Most common causes of postoperative low output&#46;</p>"
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        "identificador" => "tbl0060"
        "etiqueta" => "Table 10"
        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "Taken from <a class="elsevierStyleCrossRef" href="#bib1225">46</a> with changes by the authors&#46;"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors that usually lead to rapid deterioration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factors associated with more gradual deterioration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Rapid arrhythmia or severe bradycardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Acute coronary syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; COPD exacerbation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Mechanical complication of acute coronary syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Pulmonary embolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Kidney failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Hypertensive crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Non-compliance with diet&#47;drug regimen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Cardiac tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Iatrogenic causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Aortic dissection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Arrhythmia&#44; bradycardia&#44; conduction disorders not leading to sudden&#44; severe change in heart rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Surgical and perioperative problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Uncontrolled hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Peripartum cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Hypothyroidism and hyperthyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Alcohol and narcotics abuse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Trigger factors for acute heart failure &#40;AHF&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Stabilise haemodynamics&#46; Avoid hypoperfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Improve oxygenation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Limit heart and kidney damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Consider using mechanical circulatory support systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Improve symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Reduce length of stay in the intensive care unit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Reduce hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Therapeutic goals in acute postoperative heart failure&#46;</p>"
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        "identificador" => "tbl0070"
        "etiqueta" => "Table 12"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Cardiac</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Volume overload&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Acute heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Unstable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Acute myocardial infarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Pulmonary</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Bronchoaspiration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Pulmonary embolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Fat embolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Bronchospasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Miscellaneous</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Anxiety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Ascites with portal hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Malnutrition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Differential diagnosis of postoperative dyspnoea&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bolus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infusion rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dobutamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dopamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3-5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min &#40;beta &#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dopamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min &#40;alfa &#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Milrinone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#8211;75<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg in 10&#8211;20<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;375&#8211;0&#46;75<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Enoximone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-1&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg in 5&#8211;10<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Levosimendan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg in 10<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#44; can be reduced to 0&#46;05 or increased to 0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Norepinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;2&#8211;1&#46;0<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Epinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg IV during resuscitation&#44; repeated every 3&#8211;5<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;05&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab944425.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">With caution in hypotensive patients&#46; If bolus administration is chosen&#44; vasopressors should be available to compensate the vasodilator effect&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Positive inotropic or vasopressor drugs&#44; or both&#44; used to treat acute HF&#46;</p>"
        ]
      ]
      20 => array:7 [
        "identificador" => "tbl0080"
        "etiqueta" => "Table 14"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Systolic arterial hypotension less than 90<span class="elsevierStyleHsp" style=""></span>mmHg for more than 30<span class="elsevierStyleHsp" style=""></span>min or&#44; in hypertensive patients&#44; a reduction of 30&#37; over baseline levels maintained for more than 30<span class="elsevierStyleHsp" style=""></span>minutes&#59; hypotension is not synonymous with shock&#59; shock is generally accompanied by severe hypotension&#44; but some previously hypertensive patients can present the characteristic tissue perfusion abnormalities while showing &#8220;normal&#8221; arterial pressure levels&#46; Normal tissue perfusion can be maintained with serious hypotension if compensation mechanisms are adequate&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Signs of tissue hypoperfusion &#40;peripheral hypoperfusion due to low output and subsequent compensatory vasoconstriction&#41; and signs of vital organ dysfunction are the most specific indications of shock&#44; and evidenced by&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Lactic acidosis&#44; or the presence of one or more of the following clinical criteria secondary to a sudden or gradual decrease in tissue flow&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Pallor and cold&#44; clammy skin&#44; piloeraction and mottled cyanosis&#44; usually around the knees&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Oliguria &#40;urine output &#60;20<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#44; with urine Na levels &#60;30<span class="elsevierStyleHsp" style=""></span>mequiv&#47;l&#41;&#46; This is a fundamental sign&#44; although it can only be confirmed after one or 2<span class="elsevierStyleHsp" style=""></span>h&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; CNS depression with altered mental status secondary to insufficient blood supply to the brain &#40;obtundation&#44; agitation or confusion&#41; and intense fatigue&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Manifestations of left and&#47;or right congestive HF&#58; dyspnoea&#44; rapid&#44; shallow breathing &#40;&#62;30&#47;min&#41;&#44; rales and&#47;or jugular venous distension&#46; If auscultation does not show rales&#44; hypovolaemia should be suspected &#40;no jugular vein distension&#41; or right ventricular infarction&#44; cardiac tamponade or bradyarrhythmia &#40;with jugular vein distension&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab944439.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of cardiogenic shock&#46;</p>"
        ]
      ]
      21 => array:7 [
        "identificador" => "tbl0085"
        "etiqueta" => "Table 15"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">a&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Correct hypoxia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">b&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Administer causal therapy once the aetiology and trigger factors of the cardiogenic shock have been identified&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">c&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treat the symptoms of the main haemodynamic problems associated with the shock&#58; control heart rate&#44; optimise venous return&#44; improve contractility and reduce afterload if tolerated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">d&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Use mechanical circulatory support or balloon pump&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">e&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&#44; when advisable&#59; mainly in acute mitral valve insufficiency due to rupture of the papillary muscle&#44; the ventricular septum&#44; or post-infarction ventricular septal rupture&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab944414.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Basic therapeutic manoeuvres in left ventricle failure&#46;</p>"
        ]
      ]
      22 => array:7 [
        "identificador" => "tbl0090"
        "etiqueta" => "Table 16"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic manoeuvre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Normotensive<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>normal heart rate</td><td class="td" title="table-entry  " align="left" valign="top">IV nitroglycerine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calcium channel blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Balloon pump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Hypertension<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tachycardia</td><td class="td" title="table-entry  " align="left" valign="top">Analgesics and sedation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IV nitroglycerine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calcium channel blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Beta-blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Normotensive<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tachycardia</td><td class="td" title="table-entry  " align="left" valign="top">Analgesics and sedation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Beta-blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Increase preload&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Hypertension<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>normal heart rate</td><td class="td" title="table-entry  " align="left" valign="top">Analgesics and sedation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IV nitroglycerine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Calcium channel blockers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Alpha antagonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Hypotension<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tachycardia</td><td class="td" title="table-entry  " align="left" valign="top">Increase preload&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Alpha antagonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Balloon pump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Hypotension<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>bradycardia</td><td class="td" title="table-entry  " align="left" valign="top">Inotropes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Balloon pump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">External pacemaker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Hypotension<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>normal heart rate</td><td class="td" title="table-entry  " align="left" valign="top">Increase preload&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Inotropes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Alpha mimetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Balloon pump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab944444.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Basic therapeutic manoeuvres in postoperative myocardial ischaemia&#46;</p>"
        ]
      ]
      23 => array:7 [
        "identificador" => "tbl0095"
        "etiqueta" => "Table 17"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#46;2 and HF<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SAP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Norepinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adrenaline or dobutamine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>norepinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adrenaline or dobutamine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>norepinephrineBalloon pump or ventricular assist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SAP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 and SAP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Norepinephrine or Phenylephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adrenaline or dobutamine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>norepinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adrenaline or dobutamine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>norepinephrineBalloon pump or ventricular assist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SAP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dobutamine and levosimendan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Levosimendan<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>adrenalineBalloon pump or ventricular assist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab944423.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Use of inotropes and ventricular assist devices according to haemodynamic status&#46;</p>"
        ]
      ]
      24 => array:7 [
        "identificador" => "tbl0100"
        "etiqueta" => "Table 18"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Female sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Non-ischaemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Previous treatment &#40;ECMO&#44; Abiomed&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Need for high-dose vasopressors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Elevated GOT &#40;&#62;80<span class="elsevierStyleHsp" style=""></span>U&#47;l&#41; and bilirubin &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Severe RV dysfunction &#40;right ventricular ejection fraction &#60;205&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Severe tricuspid regurgitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Elevate central venous pressure &#40;&#62;20<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Low right ventricular stroke work index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Decrease in PAPm &#8805;10<span class="elsevierStyleHsp" style=""></span>mmHg at the start of RV treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Inodilators</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; evosimendan &#40;preconditioning in patients with predictive factors for RV failure 0&#46;05&#8211;0&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Milrinone 0&#46;375&#8211;0&#46;75<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8728; Dobutamine 2&#8211;20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">NO 4&#8211;20</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ppm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Prostaglandins</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Oral or IV sildenafil</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Adrenaline 0&#46;05&#8211;0&#46;5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#956;g&#47;kg&#47;min</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Dobutamine 0&#46;2&#8211;1&#46;0</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#956;g&#47;kg&#47;min</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; <span class="elsevierStyleItalic">Phenylephrine</span>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">Pharmacological therapy in right ventricle failure&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of evidence rated according to the GRADE system</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial quality of the evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality diminished if&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality improved if&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of the final evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Randomised clinical trial &#40;RCT&#41;</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">High</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top"><span class="elsevierStyleBold">Study limitations&#58;</span>Important <span class="elsevierStyleBold">&#40;&#8722;1&#41;</span>Very important <span class="elsevierStyleBold">&#40;&#8722;2&#41;</span><span class="elsevierStyleBold">Inconsistency&#58;</span>Important <span class="elsevierStyleBold">&#40;&#8722;1&#41;</span>Very important <span class="elsevierStyleBold">&#40;&#8722;2&#41;</span><span class="elsevierStyleBold">Direct evidence&#58;</span>Important <span class="elsevierStyleBold">&#40;&#8722;1&#41;</span>Very important <span class="elsevierStyleBold">&#40;&#8722;2&#41;</span><span class="elsevierStyleBold">Imprecision&#58;</span>Important <span class="elsevierStyleBold">&#40;&#8722;1&#41;</span>Very important <span class="elsevierStyleBold">&#40;&#8722;2&#41;</span><span class="elsevierStyleBold">Publication bias&#58;</span>Highly probable <span class="elsevierStyleBold">&#40;&#8722;1&#41;</span></td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top"><span class="elsevierStyleBold">Strength of association&#58;</span><span class="elsevierStyleHsp" style=""></span>- Scientific evidence of Strong association &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 or &#60;0&#46;5 based on observational studies with no confounding factors&#41; <span class="elsevierStyleBold">&#40;&#43;1&#41;</span>&#46;<span class="elsevierStyleHsp" style=""></span>- Scientific evidence of very Strong association &#40;RR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5 or &#60;0&#46;2 based on studies with no possible bias&#41; <span class="elsevierStyleBold">&#40;&#43;2&#41;</span>&#46;<span class="elsevierStyleBold">Dose&#8211;response gradient &#40;&#43;1&#41;</span><span class="elsevierStyleBold">Consideration of possible confounding factors&#58;</span>Possible confounding factors than could have diminished the observed effect <span class="elsevierStyleBold">&#40;&#43;1&#41;</span>&#46;</td><td class="td" title="table-entry  " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Observational studies</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Low</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Very low&nbsp;\t\t\t\t\t\t\n
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        "identificador" => "tbl0110"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col">Summary of general recommendations &#40;only includes the strongest recommendations with the highest scientific evidence&#41;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">The Lee index&#44; with its six variables&#44; should be used to assess the risk of intraoperative cardiac complications&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NT-proBNP and BNP measurements may be considered for obtaining independent prognostic information for perioperative and delayed risk of cardiac events in high-risk patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG is recommended for patients who have risk factor and are scheduled for intermediate- or high-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG may be considered for patients who have one or more risk factor and are scheduled for low-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG may be considered for patients who have no risk factor and are scheduled for intermediate-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stress testing may be considered for patients who have one or two clinical risk factors and are scheduled for high-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with acute ST-segment elevation myocardial infarction&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with acute myocardial infarction without ST-segment elevation and with unstable angina&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with angina refractory to appropriate medication&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for high-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce risks during the intervention&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce onset of clinical symptoms&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to prevent disease progression&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce morbidity and mortality&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Type of surgery&#44; the surgical technique used&#44; the urgency of the intervention &#40;postponable or not&#41; and the perioperative treatment given should be considered as independent risk factors for HF&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">The Lee index&#44; with its six variables&#44; should be used to assess the risk of intraoperative cardiac complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Laparoscopic procedures demonstrate a cardiac stress similar to that of open procedures&#44; therefore&#44; patients should undergo pre-operative risk assessment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">In high-risk patients&#44; or those requiring high complexity interventions&#44; surgery should be performed in hospitals with ample experience in the procedure&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Beta-blockers are recommended in patients with known ischaemic heart disease or myocardial ischaemia documented during preoperative stress tests&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Beta-blockers are recommended in patients scheduled for high-risk surgery &#40;<span class="elsevierStyleItalic">treatment should preferably be started between 30 days and 1 week pre-surgery</span>&#41; <span class="elsevierStyleItalic">Objectives&#58; HR&#44; 60&#8211;70<span class="elsevierStyleHsp" style=""></span>bpm&#59; Sys&#46; Pres&#46;</span> &#62;<span class="elsevierStyleItalic">100<span class="elsevierStyleHsp" style=""></span>mmHg</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Continuation of beta-blockers is recommended in patients currently receiving this medication for ischaemic heart disease or HTN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative initiation of statin therapy is recommended one month&#44; or at least one week&#44; prior to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Perioperative administration of nitroglycerine can be considered for the prevention of adverse ischaemic events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Administration of alpha 2 receptor agonists to reduce the risk of perioperative cardiovascular complications can be considered in vascular surgery patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Electrolyte abnormalities should be corrected before surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Continuation of aspirin during the perioperative period can be considered in patients previously receiving this medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Interruption of aspirin in patients previously receiving this medication should only be considered in difficult-to-control intraoperative haemostasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">It is recommended that noncardiac surgery be performed at least 6 weeks&#44; and ideally 3 months&#44; after bare metal &#40;non eluting&#41; stent implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">It is recommended that noncardiac surgery be performed at least 12 months after drug-eluting stent implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">In patients who have had recent balloon angioplasty&#44; postponement of noncardiac surgery for at least 2 weeks should be considered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prophylactic myocardial revascularization before high-risk surgery may be considered in patients with confirmed ischaemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Prophylactic myocardial revascularization before intermediate-risk surgery in patients with confirmed ischaemic heart disease is not recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Percutaneous coronary intervention or coronary artery bypass graft should be performed in accordance with prevailing CPGs on the management of stable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Provided surgery can be delayed without compromising patient safety&#44; stable angina should be diagnosed and treated in accordance with prevailing CPGs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">In the follow-up of the above cases&#44; aggressive medical treatment and myocardial revascularisation are recommended&#44; in accordance with CPGs on management of stable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Control of ventricular rate in haemodynamically unstable patients with atrial fibrillation &#40;AF&#41; is recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Antiarrhythmic drugs are recommended in patients with sustained ventricular tachycardia &#40;VT&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Thoracic epidural anaesthesia should be considered in patients with heart failure undergoing high-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Volatile anaesthetics are recommended for stable patients at risk of myocardial ischaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative anaemia increases mortality in patients with heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Restrictive transfusion strategies are recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Levosimendan is indicated in HF patients with low FEV1&#44; in the absence of severe hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative levosimendan induces preconditioning in patients with low FEV1 in both cardiac and noncardiac surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Low-dose levosimendan induces myocardial preconditioning and lowers postoperative troponin levels in heart patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IV diuretics should be administered to improve pulmonary congestion symptomatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Antithrombotic prophylaxis should be carefully reviewed in these postoperative patients&#59; it should be immediately started&#44; if this has not already been done&#44; in the absence of other contraindications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Non-invasive mechanical ventilation &#40;for example&#44; CPAP&#41; should be the therapy of choice in patients with dyspnoea and pulmonary oedema and&#47;or respiratory rate &#62;20<span class="elsevierStyleHsp" style=""></span>bpm&#46; Both non-invasive and invasive mechanical ventilation reduce arterial pressure &#40;above all&#44; with elevated PEEP&#41;&#46; It should be used with caution in hypertensive patients &#40;SAP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>85<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; Postoperative patients receiving mechanical ventilation should always be closely monitored&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">IV nitrates should be considered in patients with symptoms of pulmonary congestion&#44; provided SAP is &#62;110<span class="elsevierStyleHsp" style=""></span>mmHg and in the absence of severe mitral or aortic stenosis&#46; In the latter case&#44; vasodilators should be administered with caution and combined with invasive arterial pressure monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mechanical circulatory support should be considered early in severely hypoperfused patients&#44; despite the use of inotropes and with confirmation of a potentially reversible or correctable cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Levosimendan perfusion without a loading dose should be evaluated in patients with decompensated HF&#46; The patient should be adequately monitored&#59; at least&#44; ECG&#44; non-invasive BP and SpO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Thrombolysis is recommended as an alternative to coronary intervention&#44; although its contra-indications are similar to those of coronary intervention Risk-benefit should be evaluated individually&#44; with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery&#44; prostate surgery&#44; and interventions involving the posterior chamber of the eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Heart bypass surgery should be performed early&#44; but not urgently&#44; in patients with non-ST elevation ACS in order to reduce the risk of recurrent ACS&#46; Risk-benefit should be evaluated individually&#44; with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery&#44; prostate surgery&#44; and interventions involving the posterior chamber of the eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Urgent heart bypass surgery should be performed in haemodynamically unstable patients with ACS&#46; Risk-benefit should be evaluated individually&#44; with particular care taken in the risk-benefit evaluation of patients with brain or spinal surgery&#44; prostate surgery&#44; and interventions involving the posterior chamber of the eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Early use of ACE inhibitors or ARBs is recommended in patients with LV ejection fraction &#8804;40&#37; and ACS&#44; once stabilised&#44; in order to reduce the risk of mortality or reinfarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Early use of beta-blockers is recommended in patients with LVEF<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>40&#37; and ACS&#44; once stabilised&#44; in order to reduce the risk of mortality or reinfarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Electric cardioversion is recommended in all surgical patients with recent onset atrial fibrillation&#46; The aim must be immediate restoration of sinus rhythm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Complete anticoagulation &#40;e&#46;g&#46; IV heparin&#41;&#44; in the absence of absolute contraindications for surgery&#44; is recommended to reduce the risk of systemic arterial embolism and stroke in patients in whom sinus rhythm has not been restored&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Antibiotics for prophylaxis against endocarditis should be given to patients with valve disease or artificial valves if there is a risk of bacteraemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Invasive haemodynamic monitoring should be used in patients with moderate to severe aortic stenosis or similar severe valve disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Spinal anaesthesia is very poorly tolerated in patients with severe aortic stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intermediate risk 1&#8211;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Breast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aortic and major vascular surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Carotid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peripheral vascular surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Endocrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peripheral arterial angioplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eye&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endovascular aneurysm repair&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Head and neck surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reconstructive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurological&#47;orthopaedic-major &#40;hip and spine surgery&#41;-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Orthopaedic-minor &#40;knee surgery&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pulmonary renal&#47;liver transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Urologic-minor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urologic-major&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Risk of myocardial infarction and cardiac death within 30 days after surgery &#40;modified from Boersma et al&#46;&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Surgical risk<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> estimate&#46;</p>"
        ]
      ]
      30 => array:5 [
        "identificador" => "tbl0010"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col"><span class="elsevierStyleBold">Clinical questions&#58;</span><span class="elsevierStyleBold">Need for preoperative cardiac assessment</span>In patients with heart failure &#40;HF&#41;&#44; is preoperative cardiac assessment necessary for successful surgery&#63;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stabilised patients that have been correctly evaluated and treated do not need any kind of cardiac assessment before undergoing noncardiac surgery unless their heart failure symptoms have changed or they present stable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Weak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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      31 => array:5 [
        "identificador" => "tbl1113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col"><span class="elsevierStyleBold">Clinical questions&#58;</span><span class="elsevierStyleBold">Importance of systolic and diastolic heart failure in surgical patients</span>In patients with suspected HF&#44; are there criteria for differential diagnosis and prognosis&#63;In surgery patients with HF&#44; is there an index to grade severity or poorer prognosis for surgery&#63;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical risk indices are recommended for peri-operative risk stratification&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">The Lee index&#44; with its six variables&#44; should be used to assess the risk of intraoperative cardiac complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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      32 => array:5 [
        "identificador" => "tbl2113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col"><span class="elsevierStyleBold">Clinical questions&#58;</span><span class="elsevierStyleBold">Diagnosis of heart failure patients</span>In preoperative adult patients&#44; does clinical suspicion of HF determine the actions of the anaesthesiologist prior to surgery&#63;In adult surgical patients with suspicion of HF&#44; are there specific tests to determine the pre-anaesthesia procedure&#63;In adult surgical patients with HF&#44; should preoperative coronary angiography be performed to assess the risk of surgery&#63;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NT-proBNP and BNP measurements may be considered for obtaining independent prognostic information for perioperative and delayed risk of cardiac events in high-risk patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Systematic sampling for biomarkers to prevent cardiac complications is not recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG is recommended for patients who have risk factor and are scheduled for intermediate- or high-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG may be considered for patients who have one or more risk factor and are scheduled for low-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG may be considered for patients who have no risk factor and are scheduled for intermediate-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pre-operative ECG is not recommended for patients who have no risk factors and are scheduled for low-risk surgery&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Resting echocardiography may be considered to evaluate left ventricular function in patients scheduled for high-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Resting echocardiography to evaluate left ventricular function in asymptomatic patients is not recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stress testing is recommended in patients who have three or more clinical risk factors and are scheduled for high-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stress testing may be considered for patients who have one or two clinical risk factors and are scheduled for high-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stress testing may be considered in patients scheduled for intermediate-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Stress testing is not recommended in patients scheduled for low-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with acute ST-segment elevation myocardial infarction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with acute myocardial infarction without ST-segment elevation and with unstable angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography is recommended in patients with angina refractory to appropriate medication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for high-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography may be considered in stabilised patients who are scheduled for intermediate-risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative angiography in stabilised patients who are scheduled for low-risk surgery is not recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Weak &#8722;Level of evidence&#58; Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab944428.png"
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      33 => array:5 [
        "identificador" => "tbl3113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col"><span class="elsevierStyleBold">Clinical questions&#58;</span><span class="elsevierStyleBold">Heart failure management</span>In adult patients with HF scheduled for noncardiac surgery&#44; does the effect of the drugs administered limit the risk&#63;In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of drugs determine control of the symptoms&#63;In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of drugs prevent disease progression&#63;In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of drugs reduce morbidity and mortality&#63;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce risks during the intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce onset of clinical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to prevent disease progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative continuation of the patient&#39;s previous treatment is recommended to reduce morbidity and mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Grade of recommendation&#58; Strong &#43;Level of evidence&#58; High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "imagenFichero" => array:1 [
                0 => "xTab944446.png"
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        "identificador" => "tbl4113"
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        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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        ]
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        "identificador" => "tbl5113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
            ]
          ]
        ]
      ]
      36 => array:5 [
        "identificador" => "tbl6113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
            ]
          ]
        ]
      ]
      37 => array:5 [
        "identificador" => "tbl6013"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
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          ]
        ]
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      38 => array:5 [
        "identificador" => "tbl7113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
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          ]
        ]
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      39 => array:5 [
        "identificador" => "tbl8113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
            ]
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        ]
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      40 => array:5 [
        "identificador" => "tbl9113"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
            ]
          ]
        ]
      ]
      41 => array:5 [
        "identificador" => "tbl2013"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
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          ]
        ]
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      42 => array:5 [
        "identificador" => "tbl3013"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [ …1]
              "imagenFichero" => array:1 [ …1]
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        ]
      ]
      43 => array:6 [
        "identificador" => "tb0005"
        "tipo" => "MULTIMEDIATEXTO"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "texto" => array:1 [
          "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">A&#46;</span></span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Preoperative risk evaluation</span></p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Need for preoperative cardiac assessment</span></p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">1&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">In patients with heart failure &#40;HF&#41;&#44; is preoperative cardiac assessment necessary for successful surgery&#63;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Risk factors and risk stratification in heart failure</span></p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">In adult patients&#44; what are the risk factors for HF&#63;</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">In individuals with HF risk factors&#44; are there functional status classification systems for stratifying preoperative risk&#63;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Importance of systolic and diastolic heart failure in surgical patients</span></p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">4&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">In patients with suspected HF&#44; are there criteria for differential diagnosis and prognosis&#63;</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">5&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">In surgical patients with HF&#44; is there an index to grade severity or poorer prognosis for surgery&#63;</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Diagnosis of heart failure patients</span></p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">6&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">In preoperative adult patients&#44; does clinical suspicion of HF determine the actions of the anaesthesiologist prior to surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">7&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">In adult surgical patients with suspicion of HF&#44; are there specific tests to determine the pre-anaesthesia procedure&#63;</p></li><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">8&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">In adult surgical patients with HF&#44; should preoperative coronary angiography be performed to assess the risk of surgery&#63;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Heart failure management</span></p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">9&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">In adult patients with HF scheduled for noncardiac surgery&#44; does the effect of the drugs administered limit the risk&#63;</p></li><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">10&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of certain drugs determine control of the symptoms&#63;</p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">11&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of certain drugs prevent disease progression&#63;</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">12&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">In adult patients with HF scheduled for noncardiac surgery&#44; does the use vs&#46; non-use of certain drugs reduce morbidity and mortality&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">B&#46;</span></span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Surgical techniques&#44; anaesthetic techniques and monitoring</span></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Surgical techniques and surgery scheduling</span></p></li></ul><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">13&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; does laparoscopy reduce the stress of open-heart surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">14&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">In adult patients with high risk HF&#44; does surgery performed in specific hospitals vs&#46; non-specialised hospitals give better results&#63;</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">15&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">In adult patients with high risk HF&#44; should clinical procedures be performed prior to elective surgery in order to achieve the best results&#63;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Premedication&#44; anaesthetic techniques&#44; monitoring</span></p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">16&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">In patients with high risk HF&#44; is a particular anaesthetic technique recommended for the best outcome&#63;</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">17&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is the use of a particular anaesthetic indicated to prevent the risk of myocardial ischaemia&#63;</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">18&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; does concomitant anaemia modify the risk of morbidity and mortality&#63;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">19&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">In adult patients with HF and anaemia&#44; does a restrictive transfusion strategy vs&#46; a liberal strategy give better results&#63;</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">20&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; does pain management with NSAIDs vs&#46; COX inhibitors give better results&#63;</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">21&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; does ECG ST segment monitoring vs&#46; conventional ECG techniques give better detection of ischaemic cardiac events&#63;</p></li><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">22&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; does invasive pulmonary artery catheterisation improve intraoperative haemodynamic management&#63;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">23&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">In adult patients with HF associated with myocardial ischaemia or valve disease&#44; does TEE monitoring improve intraoperative haemodynamic management&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">C&#46;</span></span><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Preoperative pharmacological risk reduction</span></p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Beta-blockers</span></p></li></ul><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0640"><span class="elsevierStyleLabel">24&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are beta-blockers recommended vs&#46; non-fixed dose combinations in noncardiac surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">25&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; should beta-blockers be maintained vs&#46; suspended to stabilise ischaemic heart disease&#44; hypertension or arrhythmia&#63;</p></li><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">26&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are preoperative beta-blockers recommended in intermediate- or low-risk noncardiac surgery&#63;</p><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Statins</span></p></li><li class="elsevierStyleListItem" id="lsti0655"><span class="elsevierStyleLabel">27&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; should statins be used in the preoperative period vs&#46; the perioperative and postoperative period&#44; in noncardiac surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0660"><span class="elsevierStyleLabel">28&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is continuation of statins recommended vs&#46; non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery&#63;</p><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Nitrates</span></p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">29&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; should perioperative nitrates be given to prevent ischaemic events in noncardiac surgery&#63;</p><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Angiotensin-converting-enzyme inhibitors &#40;ACE inhibitors&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">30&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is continuation of ACE inhibitors recommended vs&#46; non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery to prevent decompensation or LV systolic dysfunction&#63;</p></li><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">31&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are ACE inhibitors recommended vs&#46; non-fixed dose combinations during the preoperative and perioperative stages of noncardiac surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">32&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are ACE inhibitors recommended vs&#46; suspension of ACEs in hypertensive patients&#63;</p><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Calcium channel blockers</span></p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">33&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are perioperative calcium channel blockers recommended vs&#46; non-fixed dose combinations to control ischaemic events in noncardiac surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0690"><span class="elsevierStyleLabel">34&#46;</span><p id="par0260" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are preoperative calcium channel blockers recommended vs&#46; beta-blockers in noncardiac surgery&#63;</p></li><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">35&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are preoperative calcium channel blockers recommended vs&#46; non-fixed dose combinations in high-risk noncardiac surgery to prevent cardiovascular complications&#63;</p><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Alpha-2 agonists</span></p></li><li class="elsevierStyleListItem" id="lsti0700"><span class="elsevierStyleLabel">36&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; are preoperative alpha-2 agonists recommended vs&#46; non-fixed dose combinations in noncardiac surgery to prevent cardiovascular complications&#63;</p><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Diuretics</span></p></li><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">37&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; should perioperative diuretic treatment be continued vs&#46; suspended during noncardiac surgery to prevent postoperative complications&#63;</p><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Aspirin &#40;ASA&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">38&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; should perioperative ASA be continued vs&#46; suspended to prevent postoperative complications in noncardiac surgery&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">D&#46;</span></span><p id="par0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Preoperative revascularisation as a risk reduction strategy</span></p><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Planning noncardiac surgery in stabilised patients with prior revasculisation</span></p></li></ul><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">39&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">In stabilised adult patients with CABG up to five years previously&#44; should surgery be delayed&#63;</p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">40&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Following placement of bare metal stents in adult patients&#44; should noncardiac surgery be delayed&#63;</p></li><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">41&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Following placement of drug-eluting stents in adult patients&#44; should noncardiac surgery be delayed&#63;</p></li><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">42&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Following balloon angioplasty n adult patients&#44; should noncardiac surgery be delayed&#63;</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">43&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">In adult patients with unstable angina&#44; needing urgent surgery&#44; should antiplatelet and&#47;or anticoagulant therapy be suspended&#63;</p><p id="par0335" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Prophylactic revascularisation in stablised patients</span></p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">44&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">In adult patients with HF and stabilised ischaemic heart disease&#44; should the intervention be delayed vs&#46; coronary revascularisation performed for a successful surgical outcome&#63;</p></li><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">45&#46;</span><p id="par0345" class="elsevierStylePara elsevierViewall">In adult patients with HF and stabilised ischaemic heart disease&#44; should high-risk interventions be delayed vs&#46; coronary revascularisation performed for a successful surgical outcome&#63;</p><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Prophylactic revascularisation in patients with unstable ischaemic heart disease</span></p></li><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">46&#46;</span><p id="par0355" class="elsevierStylePara elsevierViewall">In adult patients with unstable ischaemic heart disease&#44; should the intervention be delayed vs&#46; preoperative diagnosis and treatment for a successful surgical outcome&#63;</p></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">47&#46;</span><p id="par0360" class="elsevierStylePara elsevierViewall">In adult patients with a potentially fatal and concomitant surgical episode of acute coronary syndrome &#40;ACS&#41;&#44; should surgery be delayed vs&#46; ACS treated&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">E&#46;</span></span><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Therapeutic strategy for arrhythmias</span></p><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Supraventricular arrhythmia</span></p></li></ul><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">48&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">In haemodynamically stable adult patients with AF&#44; for successful surgery&#44; should the ventricular rate be monitored&#63;</p></li><li class="elsevierStyleListItem" id="lsti0775"><span class="elsevierStyleLabel">49&#46;</span><p id="par0380" class="elsevierStylePara elsevierViewall">In adult patients with SV arrhythmia&#44; should antiarrhythmic medication be maintained during the preoperative and perioperative stages&#63;</p></li><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">50&#46;</span><p id="par0385" class="elsevierStylePara elsevierViewall">In haemodynamically unstable adult patients with SV arrhythmia&#44; should electric cardioversion be performed vs&#46; vagal manoeuvres or medication before surgery&#63;</p><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Ventricular arrhythmias</span></p></li><li class="elsevierStyleListItem" id="lsti0785"><span class="elsevierStyleLabel">51&#46;</span><p id="par0395" class="elsevierStylePara elsevierViewall">In adult patients with chronic ventricular arrhythmia&#44; should preoperative and perioperative antiarrhythmic medication be maintained&#63;</p></li><li class="elsevierStyleListItem" id="lsti0790"><span class="elsevierStyleLabel">52&#46;</span><p id="par0400" class="elsevierStylePara elsevierViewall">In haemodynamically unstable adult patients with chronic ventricular arrhythmia&#44; should antiarrhythmic medication be maintained vs&#46; electric cardioversion performed&#63;</p><p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Implantable devices</span></p></li><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">53&#46;</span><p id="par0410" class="elsevierStylePara elsevierViewall">In adult patients with arrhythmia&#44; should devices be implanted preoperatively vs&#46; postoperatively&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0800"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">F&#46;</span></span><p id="par0415" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Use of inotropic drugs</span></p><p id="par0420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Dopamine&#44; dobutamine&#44; phosphodiesterase III inhibitors</span></p></li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">54&#46;</span><p id="par0425" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is intraoperative dopamine recommended vs&#46; other inotropic drugs&#63;</p><p id="par0430" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Levosimendan</span></p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">55&#46;</span><p id="par0435" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is intraoperative levosimendan recommended vs&#46; other medication&#63;</p></li><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel">56&#46;</span><p id="par0440" class="elsevierStylePara elsevierViewall">In adult patients with HF&#44; is levosimendan recommended vs&#46; other medication for intraoperative myocardial preconditioning&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">G&#46;</span></span><p id="par0445" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Therapeutic strategies for acute postoperative HF</span></p><p id="par0450" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patients with pulmonary congestion&#47;pulmonary oedema without shock</span></p></li></ul><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">57&#46;</span><p id="par0455" class="elsevierStylePara elsevierViewall">In adult patients with pulmonary congestion&#47;pulmonary oedema without shock&#44; are inotropes recommended vs&#46; other drugs &#40;vasodilators&#44; diuretics&#44; opioids&#41; to improve the clinical situation&#63;</p></li><li class="elsevierStyleListItem" id="lsti0830"><span class="elsevierStyleLabel">58&#46;</span><p id="par0460" class="elsevierStylePara elsevierViewall">In adult patients with pulmonary congestion&#47;pulmonary oedema without shock&#44; should high FiO<span class="elsevierStyleInf">2</span> be administered by spontaneous ventilation vs&#46; mechanical ventilation to improve the clinical situation&#63;</p></li><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">59&#46;</span><p id="par0465" class="elsevierStylePara elsevierViewall">In adult patients with pulmonary congestion&#47;pulmonary oedema without shock&#44; is early antithrombotic prophylaxis recommended vs&#46; delayed antithrombotic prophylaxis to prevent thromboembolic complications&#63;</p><p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patients with low output&#44; hypotension&#44; hypoperfustion or shock</span></p></li><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">60&#46;</span><p id="par0475" class="elsevierStylePara elsevierViewall">In adult patients with low output&#44; hypotension&#44; hypoperfusion or shock&#44; is cardioversion recommended vs&#46; medication to restore sinus rhythm and haemodynamics&#63;</p></li><li class="elsevierStyleListItem" id="lsti0845"><span class="elsevierStyleLabel">61&#46;</span><p id="par0480" class="elsevierStylePara elsevierViewall">In adult patients with low output&#44; hypotension&#44; hypoperfusion or shock&#44; are inotropes recommended vs&#46; other medication to improve the clinical situation&#63;</p></li><li class="elsevierStyleListItem" id="lsti0850"><span class="elsevierStyleLabel">62&#46;</span><p id="par0485" class="elsevierStylePara elsevierViewall">In adult patients with low output&#44; hypotension&#44; hypoperfusion or shock&#44; are mechanical circulatory support systems recommended vs&#46; medication to restore haemodynamics and tissue perfusion&#63;</p></li><li class="elsevierStyleListItem" id="lsti0855"><span class="elsevierStyleLabel">63&#46;</span><p id="par0490" class="elsevierStylePara elsevierViewall">In adult patients with low output&#44; hypotension&#44; hypoperfusion or shock&#44; is cardioversion recommended vs&#46; medication to restore sinus rhythm and haemodynamics&#63;</p><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Surgical patients with acute coronary syndrome &#40;ACS&#41;</span></p></li><li class="elsevierStyleListItem" id="lsti0860"><span class="elsevierStyleLabel">64&#46;</span><p id="par0500" class="elsevierStylePara elsevierViewall">In adult surgical patients with ACS&#44; is urgent coronary intervention recommended vs&#46; revascularisation to reduce the area of necrosis&#63;</p></li><li class="elsevierStyleListItem" id="lsti0865"><span class="elsevierStyleLabel">65&#46;</span><p id="par0505" class="elsevierStylePara elsevierViewall">In adult surgical patients with ACS&#44; are there alternative treatments to urgent coronary intervention or revascularisation to reduce the area of necrosis&#63;</p></li><li class="elsevierStyleListItem" id="lsti0870"><span class="elsevierStyleLabel">66&#46;</span><p id="par0510" class="elsevierStylePara elsevierViewall">In adult surgical patients with ACS&#44; are there alternative drug therapies to reduce secondary morbidity and mortality&#63;</p><p id="par0515" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patients with AF with rapid ventricular response</span></p></li><li class="elsevierStyleListItem" id="lsti0875"><span class="elsevierStyleLabel">67&#46;</span><p id="par0520" class="elsevierStylePara elsevierViewall">In adult surgical patients with ACS&#44; is electric cardioversion recommended vs&#46; medical cardioversion for rapid restoration of the sinus rhythm&#63;</p><p id="par0525" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Patients with severe bradycardia</span></p></li><li class="elsevierStyleListItem" id="lsti0880"><span class="elsevierStyleLabel">68&#46;</span><p id="par0530" class="elsevierStylePara elsevierViewall">In adult surgical patients with ACS and severe bradycardia&#44; are external pacemakers indicated to restore haemodynamic stability&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0885"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">H&#46;</span></span><p id="par0535" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Strategy in patients with valve disease needing noncardiac surgery</span></p></li></ul><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0890"><span class="elsevierStyleLabel">69&#46;</span><p id="par0540" class="elsevierStylePara elsevierViewall">In adult patients with valve disease&#44; are there specific monitoring protocols to prevent perioperative complication&#63;</p></li><li class="elsevierStyleListItem" id="lsti0895"><span class="elsevierStyleLabel">70&#46;</span><p id="par0545" class="elsevierStylePara elsevierViewall">In adult patients with valve disease&#44; are there pre-noncardiac surgery therapeutic alternatives to optimise haemodynamics&#63;</p></li><li class="elsevierStyleListItem" id="lsti0900"><span class="elsevierStyleLabel">71&#46;</span><p id="par0550" class="elsevierStylePara elsevierViewall">In adult patients with valve disease&#44; are there specific optimal anaesthetic techniques vs&#46; other poorly tolerated anaesthetic techniques&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0905"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">I&#46;</span></span><p id="par0555" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Strategy in patients with pulmonary hypertension &#40;PH&#41;</span></p></li></ul><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0910"><span class="elsevierStyleLabel">72&#46;</span><p id="par0560" class="elsevierStylePara elsevierViewall">In adult patients with PH&#44; should existing medication be maintained vs&#46; administration of other medication&#63;</p></li><li class="elsevierStyleListItem" id="lsti0915"><span class="elsevierStyleLabel">73&#46;</span><p id="par0565" class="elsevierStylePara elsevierViewall">In adult patients with PH&#44; should specific anaesthesia monitoring techniques be used to ensure the best possible surgical conditions&#63;</p></li><li class="elsevierStyleListItem" id="lsti0920"><span class="elsevierStyleLabel">74&#46;</span><p id="par0570" class="elsevierStylePara elsevierViewall">In adult patients with PH&#44; are there anaesthetic techniques vs&#46; surgical interventions that are poorly tolerated&#63;</p></li></ul></p></span>"
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Article information

ISSN: 23411929
Original language: English

DOI:10.1016/j.redare.2015.05.001

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