Authors: Noutsios D et al.
Canadian Journal of Anesthesia December 2025.
Summary
This historical cohort study evaluated adherence to the 2016 Canadian Cardiovascular Society (CCS) guidelines for perioperative cardiac risk assessment in patients undergoing elective noncardiac surgery at a Canadian quaternary care center. The CCS guidelines emphasize the use of cardiac biomarkers, particularly preoperative B-type natriuretic peptide (BNP) and postoperative troponin monitoring, to improve detection of perioperative cardiac risk and postoperative myocardial injury.
The authors reviewed 3,623 adult patients who underwent elective noncardiac surgery requiring an overnight hospital stay between January 2018 and December 2019 at the McGill University Health Centre. The primary outcome was adherence to recommended preoperative BNP measurement. Secondary outcomes included adherence to postoperative troponin and electrocardiogram (ECG) acquisition, as well as 30-day postoperative cardiac outcomes.
Overall adherence to guideline-recommended testing was suboptimal. Only 52.4% of eligible patients underwent preoperative BNP screening. Postoperative surveillance adherence was even lower, with troponin and ECG acquisition rates of 34.6% and 30.5%, respectively. Despite this limited adherence, the prognostic value of biomarker testing was clear. Patients with elevated preoperative BNP levels experienced significantly higher rates of myocardial injury after noncardiac surgery, myocardial infarction, and 30-day mortality. Similarly, elevated postoperative troponin levels were strongly associated with increased rates of myocardial infarction and death within 30 days.
The study also found that abnormal biomarker results were associated with increased physician follow-up, suggesting that clinicians responded appropriately when high-risk findings were identified. However, the inconsistent application of guideline-recommended testing limited the broader impact of this strategy. The authors conclude that while biomarker-based risk stratification identifies patients at high risk for adverse cardiac outcomes, greater adherence to CCS guidelines is needed, along with further research into how expanded testing influences long-term outcomes and clinical decision-making.
Key Points
Adherence to CCS guideline–recommended BNP screening before noncardiac surgery was approximately 50%.
Postoperative troponin and ECG monitoring adherence was low, occurring in roughly one-third of patients.
Elevated preoperative BNP was strongly associated with myocardial injury, myocardial infarction, and 30-day mortality.
Elevated postoperative troponin was associated with markedly increased myocardial infarction and mortality rates.
Improved guideline adherence and further evaluation of biomarker-driven risk stratification strategies are needed.
Thank you for allowing us to review and summarize this important perioperative outcomes study from the Canadian Journal of Anesthesia.