Introduction. 
Nowadays a clearly defined tendency to aging contingent of patients with a high frequency in concomitant cardiovascular diseases (CVD) is revealed in surgery. In this regard, we need to have a unified system of cardiac risk stratification, which can take into account the whole variety of existing cardiovascular pathology, methods of diagnosis and treatment and give an anesthesiologist an algorithm of actions when working with the mentioned category of patients. In 2014 the ESA/ ESC published guidelines on management of patients with concomitant cardiovas-cular pathology in non-cardiac surgery.

Objective.
In the clinical setting to assess the convenience and efficiency of some of the most important and up-date regulations of the mentioned clinical guidelines in high-risk cardiac patients undergoing extensive and traumatic operations in thoracic surgery, as well as the frequency and structure of perioperative cardiovascular complica-tions and long-term outcomes of treatment in their application.

Materials and methods.
A group of 20 patients was studied; in the conditions of the combined endotracheal anesthesia with Sevorane and Fentanyl in combination with prolonged epidural (EDA) or intrapleural analgesia (IPA) with Naropin they underwent lobectomy through thoracotomy. 
A 'Standard' set of clinical laboratory and instrumental studies was supplemented by echocardiography and 12-lead ECG followed by consulting with cardiologist (arrhythmologist, cardiac surgeon). In addition, in the preoperative period surgical risk stratification was conducted on the basis of the planned volume of operation and the risk of complications in the CVS (modified Lee Index). Assessment of the
patient's functional reserves was based on the calculation of metabolic equivalent intensity (MET). In addition, an initial level of Troponin I (Tr 1) was determined in all patients of this group. 
According to the results, we solved the issue of carrying out additional therapeutic and diagnostic tests such as bicycle ergometry (BEM), daily control of Holter ECG (HM), coronary angiography/angioplasty (CAG/CAP) and correction of therapy by including beta-blockers (BAB), angiotensin-converting enzyme (ACE) inhibitors and statins. During anesthesia and postoperative period we assessed some data. They included the incidence of arterial hypotension (decrease in MAP at 20% or a level of MAP less than 60 mmHg for 30 minutes or more). We also had control over the severity of intraoperative period according to the Surgical Apgar Score in points, frequency and nature of such complications as acute myocardial infarction (AMI), paroxysmal rhythm disturbances, acute cerebrovascular accident (CVA) and pulmonary embolism (PE), as well as 30-day mortality resulted from them. 
Finally, Troponin I (Tr 1) was determined in 24, 48 and 72 h. after the operation and a quality of analgesia was evaluated in points according to the visual analogue scale (VAS) based on narcotic analgesics (2% solution of Promedol) and regional analgesia (0.2% solution of Naropin, epidural or intrapleural analgesia).

Results and Discussion. 
All the patients of the studied group were classified as high-risk category (> 5%), based on anticipated (and performed) surgery volume.
The value of the modified Lee Index was 3.3 ± 0.4, that along with the character of the operation was due to the presence of cardiovascular pathology in all patients in various combinations and insulin-dependent diabetes mellitus in 3 cases (15%). The value of MET estimated using an appropriate questionnaire was 4.8 ± 0.7.
     The initial level of Troponin I did not go beyond the normal range (0-0.5 ng/ml) and it was 0.25 ± 0.05 ng/ml in all patients. The data stated above, make it possible to characterize these patients as severe with a high risk of complications in the CVS, and therefore requiring the most careful attention and a number of special 
diagnostic and treatment approaches to refine the tactics. Thus, bicycle ergometry (BEM) was held in 5 patients (25%), and Holter ECG (HM) - 6 patients (30%). The combined use of these methods was considered appropriate in 3 persons (15%), coronary angiography (CAG) with implantation of metal stents was later performed in 2 of them (10%). And it was followed by administration of dual 
antiplatelet therapy (DAT) and a 6 week delay of the operation. Therapy with BAB and statins was performed in 12 patients (60%) before the operation. During the preoperative examination statins were administered to all patients and BAB – to 5 patients more (25%); moreover the dose was subjected to correction in 9 patients (75%) from this group who took them before. As for ACE inhibitors, the number of patients treated with them before the operation was increased from 14 (70%) up to 20 (100%), but 7 patients (50%) required a dose correction, and it indirectly 
indicates a relative weak spot of the primary therapeutic level. 
It should be emphasized that these changes in drug therapy have been carried out no later than one week before the upcoming operation. In the intraoperative period clinically significant arterial hypotension (AH) was detected in 4 patients (20%). It was caused by the blood loss in volume over 1000 ml in 3 patients (15%), and 1 patient (5%) had rhythm disturbances in the form of paroxysmal atrial fibrillation (AF). In the first case hemodynamics was restored by intensive infusion-transfusion therapy (ITT) with a hemoglobin target level not less than 90 g/l in combination with inotropic support in low doses of Noradrenaline (0.2-0.3 mg/kg *min). Paroxysmal atrial fibrillation was successfully arrested with Cordarone (450 mg) but in the background of its application and in this case it became 
necessary to use Noradrenaline (0.1-0.2 ug / kg * min) and this can be associated with the summation of the hypotensive effect of this drug and preparations for 
general and regional anesthesia.
      In 2 of the above 4 cases downsloping ST segment depression in leads V1-V3 was noticed which coincided in time with LBP and was stopped independently un-til hemodynamics became stabilized. All the patients received less than 7 points on the Surgical Apgar Score, which was quite expected, taking account of the volume of the operation and the severity of concomitant cardiac pathology. The patients were moved to the intensive care unit for the further treatment (8 of them (40%) for the prolonged respiratory support), and they spent there 48 hours. During the operation 1 patient (5%) with paroxysmal atrial fibrillation (AF) had the recurrence of this state which was arrested with Cordarone and signs of myocardial ischemia were not registered. 
      The earliest reinitiation of the pre-operative therapy (at once after restoring the ability to take fluid per os) was given particular importance, as well as permanent oxygen therapy through a face mask (6 - 8 l/min) and effective post-operative 
analgesia which leading component was EDA (16persons, 80%) or IPA (4 persons, 20%). The latter was used in the patients receiving dual antiplatelet therapy (DAT) before the operation (2 persons, 10%) or those who were transferred from oral 
administration of Warfarin to the therapy with medical doses of Clexane. All the patients achieved the target level of analgesia both at rest (≤ 3 points on the VAS), and during deep breathing and coughing (≤ 4 points on the VAS). 
      The concentration of Tr1 measured in 24, 48 and 72 hours after the operation 
respectively was 0.73 ± 0.08 ng / ml, 0.65 ± 0.06 ng / ml and 0.58 ± 0.05 ng / ml, which was higher than the initial preoperative level. At the same time, it did not significantly exceed the upper limit of the norm and tended to decrease over time. The most important thing is that other clinical, electrocardiographic, instrumental (echocardiography) and laboratory signs of myocardial damage did not follow it.                    Most likely, these changes were due to mechanical compression of the myocardi-um during the operation, electrocoagulation of nearby tissues in the chest wall and the lung. During the month 2 patients (10%) suffered from serious complications in the CVS: AMI (transmural) -18 days later after the operation and massive PE - on the 25-th day, which led to death.
This index corresponds to the category of high-risk surgical patients who scored 3 or more points according to the Lee Index, and it is not significantly different from the European average level.

Conclusion. Thus, guidelines proposed by ESA/ESC appear to be effective, rela-tively simple and convenient in the clinic, allowing an anesthesiologist to choose tactics of the perioperative management of patients with cardiovascular pathology in non-cardiac surgery and this increases a safety level and leads to better treatment outcomes.

First experience with the new European guidelines preoperative management of patients with concomitant cardiac pathology in non-cardiac surgery