Unwanted silent crosstalk: Troponinemia and surgeons

Abstract

The release of serum cardiac troponins (cTn) following major non-cardiac surgery (MNCS) is associated with significant adverse postoperative outcomes. This phenomenon comprises myocardial injury after non-cardiac surgery (MINS) or perioperative myocardial infarction that may occur regardless of the presence of obstructive coronary artery disease (CAD). However, there is no consensus on its diagnostic criteria or therapeutic guidelines. The 30-day mortality following MNCS is 2%-6% and more than half of these deaths are attributable to the major adverse cardiovascular events (MACEs). Although MINS is an independent predictor of MACEs, it is not the only prognostic tool. The release of cTn may be secondary to perioperative tachycardia, hypotension, anemia, hypoxia, sepsis, inflammation, and profound stress. In the latter, an adrenergic surge, independent of underlying CAD, can cause a noticeable release of cTn. Even low levels of cTn elevation within the first three days after high-risk surgery are correlated with a significant increase in the short- and long-term mortality rates. Therefore, awareness of this phenomenon is of utmost value for better perioperative management and prognostication. The patient, surgery (type, duration, and urgency), and cTn (timing, type, and frequency) should be considered in MINS identification and interpretation. Appropriate management necessitates index of suspicion and multidisciplinary stepwise actions.

Keywords: Troponinemia; Perioperative; Major non-cardiac surgery; Myocardial injury after non-cardiac surgery; Surgery; Mortality; Cardiac biomarker

Core Tip: The Major non-cardiac surgery is associated with a significant risk of perioperative mortality. This adverse outcome relies mainly on the occurrence of myocardial injury in the perioperative settings. Myocardial injury after non-cardiac surgery remains widely unrecognized, partly because there is no universal consensus on its definition and diagnostic criteria. However, a working diagnosis can be established based on an elevated post-operative cardiac troponin level within 30 days of surgery after excluding other non-ischemic causes, regardless of whether the patient has symptoms or electrocardiogram findings. There is growing consensus for proactive surveillance to mitigate the burden of perioperative cardiovascular complications.