Radius Anesthesia Blog
Cardiac complications are a significant driver of postoperative morbidity and mortality in patients undergoing noncardiac surgery. The physiological stress of surgery can lead to myocardial ischemia, arrhythmias, or heart failure, especially in patients with preexisting cardiovascular disease. Even for noncardiac surgery, effective cardiac risk assessment allows the clinical team to optimize perioperative care and reduce the incidence of major adverse cardiac events (MACE).
Traditionally, the Revised Cardiac Risk Index (RCRI) has guided clinicians in evaluating perioperative cardiac risk by relying on clinical predictors such as ischemic heart disease, heart failure, cerebrovascular disease, diabetes requiring insulin, renal insufficiency, and high-risk surgery. However, the RCRI is limited in its ability to detect subclinical myocardial injury. Recent strategies have incorporated cardiac biomarkers, such as B-type natriuretic peptide (BNP) and troponins, to improve risk stratification. BNP reflects myocardial wall stress, and troponins indicate myocardial injury. These biomarkers provide objective data beyond clinical risk indices.
A recent historical cohort study at McGill University examined adherence to Canadian Cardiovascular Society (CCS) guidelines for perioperative cardiac risk assessment in patients undergoing elective noncardiac surgery (1). Of the 3,623 patients, only 52.4% underwent preoperative BNP testing, and fewer had postoperative troponin monitoring. Elevated BNP and troponin levels were independently associated with higher rates of myocardial injury, infarction, and mortality within 30 days. These results highlight the importance of guideline-recommended biomarker screening for improving risk detection and postoperative outcomes.
The VISION study also highlighted the prognostic value of troponin surveillance, demonstrating that even mild postoperative troponin elevations are significantly associated with increased 30-day mortality following noncardiac surgery (2). Notably, most of these myocardial injuries occurred without ischemic symptoms, suggesting that traditional, symptom-based monitoring may overlook at-risk patients. Additional evidence from the Myocardial Injury after Noncardiac Surgery (MINS) cohort confirmed that silent troponin elevations carry a substantial risk of short- and long-term mortality (3).
In light of this evidence, the CCS and ACC/AHA guidelines both advocate a structured, risk-based approach to perioperative cardiac assessment in the setting of noncardiac surgery. The CCS 2017 guidelines recommend BNP and troponin testing for patients aged 65 years or older or those with significant cardiac comorbidities undergoing intermediate- or high-risk surgery. Similarly, the ACC/AHA guidelines suggest reserving advanced imaging for patients with poor functional capacity or active cardiac symptoms (5).
Despite strong evidence supporting these recommendations, adherence to perioperative cardiac evaluation protocols remains suboptimal. The McGill study’s findings illustrate an important implementation gap: although biomarker testing can significantly improve risk stratification, it is underused in clinical practice. Increasing awareness, integrating decision-support tools into preoperative workflows, and fostering collaboration between anesthesiology, cardiology, and surgery can help improve adherence to protocols and patient outcomes.
Cardiac assessment after noncardiac surgery is advised for patients with elevated risk, such as older adults and those with cardiac comorbidities, and should incorporate traditional risk indices, biomarker evaluation, and personalized monitoring strategies. Biomarkers such as brain natriuretic peptide (BNP) and troponin provide critical prognostic insights, enabling earlier detection and intervention for myocardial injury. Adhering to established guidelines and systematically incorporating biomarker-driven assessments into perioperative care can meaningfully reduce the burden of cardiac complications and improve surgical outcomes.
References
1. Noutsios D, Marino A, Anacleto-Dabarno M, Baldini G, Bessissow A. Cardiac risk assessment after noncardiac surgery: a historical cohort study on guideline adherence at a Canadian quaternary care centre. Can J Anaesth. Published online December 1, 2025. doi:10.1007/s12630-025-03040-z
2. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux PJ, Chan MT, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295-2304. doi:10.1001/jama.2012.5502
3. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120(3):564-578. doi:10.1097/ALN.0000000000000113
4. Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32. doi:10.1016/j.cjca.2016.09.008
5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944