What is the role of cardiac biomarkers in preoperative evaluation for non-cardiac surgery?

From the Guidelines

Cardiac biomarkers, particularly natriuretic peptides (BNP and NT-proBNP) and troponins, play a valuable but limited role in preoperative evaluation for non-cardiac surgery, and should not be routinely measured in all surgical patients, but rather reserved for high-risk patients with known or suspected cardiac disease undergoing major procedures. The use of these biomarkers is supported by studies such as the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Key Points to Consider

• Elevated preoperative natriuretic peptide levels (BNP >92 pg/mL or NT-proBNP >300 pg/mL) indicate increased risk of perioperative cardiac complications and mortality, while troponin elevation suggests myocardial injury that may warrant further cardiac evaluation or optimization before elective surgery 1.
• The value of these biomarkers lies in their ability to identify subclinical cardiac dysfunction that might not be apparent through standard clinical assessment 1.
• Biomarker testing should complement, not replace, comprehensive clinical evaluation including history, physical examination, and functional capacity assessment 1.
• The cost-effectiveness of routine biomarker screening remains questionable for low-risk patients undergoing minor procedures, where the predictive value is limited and unlikely to change management 1.

Clinical Application

When abnormal biomarkers are detected, the surgical team should consider additional cardiac testing, optimization of medical therapy, closer perioperative monitoring, or possibly postponing elective procedures 1. The goal of preoperative evaluation is to promote patient engagement and facilitate shared decision making by providing patients and their providers with clear, understandable information about perioperative cardiovascular risk in the context of the overall risk of surgery 1.

Limitations and Future Directions

The evidence base for the predictive value of biomarkers in the perioperative period has grown, but the utility of this information in influencing management and outcome is unknown and is currently undergoing investigation 1. Future research will be needed to understand how information on perioperative risk is incorporated into patient decision making and to assess the utility of biomarker testing in preoperative evaluation 1.

From the Research

Role of Cardiac Biomarkers in Preoperative Evaluation

The use of cardiac biomarkers in the preoperative evaluation of patients scheduled for non-cardiac surgery is a crucial aspect of assessing cardiovascular risk.

• Cardiac biomarkers can help identify patients at high risk of perioperative cardiovascular complications, such as myocardial infarction and major adverse cardiovascular events 2, 3.
• However, routine preoperative cardiac testing, including biomarker assessment, is not recommended for patients at low risk of major adverse cardiovascular events 2, 4.
• Individualized preoperative cardiac evaluation, taking into account factors such as functional capacity, type of surgery, cardiac risk factors, and cardiovascular function, is emphasized in current guidelines 4, 5.
• The goal of preoperative cardiac management is to improve overall patient outcome by identifying and managing cardiovascular disease, predicting cardiovascular risk, and optimizing perioperative care 6.

Factors Influencing Cardiac Biomarker Use

Several factors influence the use of cardiac biomarkers in preoperative evaluation, including:

• Patient-specific risk factors, such as age, coronary artery disease, and cardiovascular function 2, 3.
• Type of surgery, with high-risk surgeries requiring more thorough evaluation 4, 5.
• Functional capacity, with patients having poor functional capacity requiring more extensive assessment 2, 4.
• Presence of coronary stents, which increases the risk of perioperative myocardial infarction and major adverse cardiovascular events 2, 3.

Limitations and Future Directions

While cardiac biomarkers can provide valuable information in preoperative evaluation, their use is not without limitations.

• Excessive evaluation can lead to undue resource utilization and surgical delay 3.
• Current guidelines do not provide detailed recommendations on the management of antiplatelet therapy in patients with coronary artery disease undergoing non-cardiac surgery 3.
• Further research is needed to determine the optimal approach to preoperative risk stratification and periprocedural management of patients with coronary artery disease undergoing non-cardiac surgery 3.