Perspective:

This article reviews the significant mortality burden and frequently asymptomatic presentation of myocardial injury after noncardiac surgery (MINS), summarizing findings from relevant outcome studies, and exploring the rationale for considering routine troponin monitoring in at-risk patients undergoing noncardiac surgery (NCS).

Real-time recognition of MINS provides an opportunity for timely intervention that could mitigate risk, based on: 1) post hoc observational data from the POISE trial demonstrating an association between both aspirin and statin therapy and decreased 30-day postoperative mortality, and 2) results from a small case-control study of vascular surgery patients showing improved survival among those in whom protective therapy (aspirin, statin, beta-blocker, and/or angiotensin-converting enzyme inhibitor) was initiated or intensified prior to hospital discharge. Accordingly, such medications with proven protective benefit in nonoperative settings should be considered, and if possible implemented, in patients with MINS.

The apparent protective benefits of low- and intermediate-dose anticoagulation in the MANAGE and COMPASS trials suggest that thrombosis is a major driver of MINS-related harm. The importance of weighing the risk-benefit relationship of anticoagulation in the postoperative period is addressed.

Findings from computed tomography coronary angiography studies demonstrating that a large proportion of patients with MINS have underlying obstructive or extensive atherosclerotic coronary artery stenosis are presented. Although the authors argue that referral for coronary angiography should be reserved for MINS patients showing ongoing instability (heart failure, ischemic symptoms), understanding the true cost-benefit of postoperative revascularization could be determined by a future randomized trial.

Given: 1) the frequently asymptomatic presentation of MINS, 2) prevalence of advanced underlying coronary disease in affected patients, and 3) evidence suggesting that available treatments may reduce subsequent morbidity and mortality, the authors argue that troponin should be routinely measured on postoperative days 1-3 in patients aged ≥65 years and/or with known atherosclerotic disease after NCS to avoid missing an opportunity to provide beneficial intervention to a high-risk population.