High-Sensitivity Troponin in Noncardiac Surgery: Pandora’s Box or Opportunity for Precision Perioperative Care?

Article, see p 1221 Worldwide, an estimated 200 million noncardiac surgeries are performed each year.1 As many as 10 million of these surgeries have overt cardiovascular complications that lead to worse clinical outcomes, including increased risk of death in short-term follow-up.2 A recent report from the VISION Study (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) investigators suggested that these overt cardiovascular complications are just the tip of the iceberg. Among 21 842 patients ≥45 years of age undergoing noncardiac surgery at 23 centers worldwide, nearly 1 in 5 had evidence of myocardial injury as determined by elevated high-sensitivity troponin T (hsTnT) in the first 3 days postoperatively, 93% without any ischemic symptoms to support a diagnosis of myocardial infarction.3 Further, there was a graded increase in 30-day mortality with higher hsTnT levels. However, despite the clear association of hsTnT elevation with 30-day mortality, whether routine screening for postoperative hsTnT elevation would lead to care decisions or interventions that improve clinical outcomes or, conversely, opens a Pandora’s box of additional testing and treatment with potentially unintended consequences is an unanswered question. In this issue of Circulation , Puelacher and colleagues4 offer additional insights into the frequency, clinical presentation, and risk associated with perioperative myocardial injury (PMI) among higher-risk patients undergoing noncardiac surgery that suggest the importance of answering this question. They examined PMI among 2018 consecutive patients at increased risk for cardiovascular complications (≥65 years of age or ≥45 years of age with a history of coronary artery disease, peripheral artery disease, or stroke) who underwent 2546 noncardiac surgeries at a single hospital. It is important to know that hsTnT was systematically assessed both pre- and postoperatively as part of a standard-of-care protocol that included specific assessments and an automatic trigger for cardiology consultation for patients with …