Evaluation of the cardiovascular risk in patients undergoing major non-cardiac surgery: role of cardiac-specific biomarkers

Abstract

Major adverse cardiovascular events are frequently observed in patients undergoing major non-cardiac surgery during the peri-operative period. At this time, the possibility to predict cardiovascular events remains limited, despite the introduction of several algorithms to calculate the risk of adverse events, mainly death and major adverse cardiovascular events (MACE) based on the clinical history, risk factors (sex, age, lipid profile, serum creatinine) and non-invasive cardiac exams (electrocardiogram, echocardiogram, stress tests). The cardiac-specific biomarkers natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the peri-operative period, particularly for the identification of myocardial injury in patients undergoing major non-cardiac surgery. The prognostic information from the measurement of BNP/NT-proBNP and hs-cTn is independent and complementary to other important indicators of risk, also including ECG and imaging techniques. Elevated levels of cardiac-specific biomarkers before surgery are associated with a markedly higher risk of MACE during the peri-operative period. BNP/NT-proBNP and hs-cTn should be measured in all patients during the clinical evaluation before surgery, particularly during intermediate- or high-risk surgery, in patients aged >65 years and/or with comorbidities. Several questions remain to be assessed in dedicated clinical studies, such as how to optimize the management of patients with raised cardiac specific biomarkers before surgery, and whether a strategy based on biomarker measurement improves patient outcomes and is cost-effective.

Discovery of plasma proteome markers associated with clinical outcome and immunological stress after cardiac surgery

“…Creating combined scores consisting of multiple biomarkers might be a promising new approach for predicting outcome after cardiac surgery and our findings yielded potential candidates for further evaluation. As a most prominent example, the introduction of the cardiac-specific biomarkers natriuretic peptides and cardiac troponins have substantially refined the prognostication of cardiovascular risk in non-cardiac surgery, both independently and complementary to other important indicators of risk ( 49 ). Other recent studies have assessed the predictive power of other multimodal scores consisting of hit-proteins and previously identified risk factors such as age, haemoglobin values or serum lactate concentrations to predict neurologic outcomes in emergency patients undergoing cardiac surgery after out-of-hospital cardiac arrest ( 50 ).…”

Cardiovascular risk management in the peri‐operative setting

“…One such systematic review and meta‐analysis of 2179 patients from 18 studies found that elevated pre‐operative BNP (> 92 mg/L) or NT‐proBNP (> 300 ng/L) was the strongest independent predictor of death and non‐fatal myocardial infarction at 30 days (odds ratio [OR], 3.7; 95% CI, 2.2–6.2; P < 0.001) and at 180 days or more (OR, 2.2; 95% CI, 1.9–2.7; P < 0.001) after surgery 45 . Yet, there is no consensus on thresholds at which increased risk is conferred and on how they add value to existing risk prediction strategies 16,46,47 . In a prospective observational study of 979 patients, elevated pre‐operative hsTnT was the strongest independent predictor for the combined endpoint of in‐hospital mortality, myocardial infarction, cardiac arrest, cardiopulmonary resuscitation, and acute decompensated heart failure (hazard ratio, 2.6; 95% CI, 1.3–5.3; P = 0.01) 48 .…”

The Relevance of Implementing the Systematic Screening of Perioperative Myocardial Injury in Noncardiac Surgery Patients

“…In recent years, several national and international guidelines [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ] have issued recommendations for the systematic screening of PMI using hs-cTn, instead of relying only on clinical symptoms. Despite the demonstrated efficiency and cost-effectiveness of systematic PMI screening with hs-cTn [ 15 ], especially for high cardiovascular risk patients undergoing major surgeries [ 16 ], its implementation is still limited in clinical practice.…”