Cardiac biomarkers and risk assessment in patients undergoing major non-cardiac surgery: time to revise the guidelines?

Although the perioperative event rate has declined over the past 30 years, as a consequence of the developments in anesthesiology and surgical techniques, perioperative cardiovascular complications are still a significant clinical problem. At the end of the last century, a pooled analysis of several large studies found a 30-day incidence of cardiac events of 2.5% in unselected patients aged >40 years. The identification of myocardial injury after non-cardiac surgery is a problematic and tough challenge, since up to 50% of cardiac deaths actually occur in patients with no history of overt heart disease. Recently, among novel sensitive and specific cardiovascular risk markers, the European Society of Cardiology and European Society of Anesthesiology guidelines for preoperative cardiac risk assessment have recommended that preoperative brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) measurement should be considered in high-risk patients undergoing non-cardiac surgery. However, several recent studies and meta-analyses, published in the last 5 years, strongly support the use of both assays of cardiac B-type natriuretic peptides and troponins, for risk stratification in patients undergoing non-cardiac surgery, in order to improve operative and postoperative outcome. Indeed, an increase in specific cardiac biomarkers, as it is the case for natriuretic peptides and troponins, always indicates that the heart is under a stress condition or even actually injured, respectively. In conclusion, the authors suggest that future guidelines on cardiovascular risk evaluation in patients undergoing major surgical procedures should take into account the following evidence.