Preoperative Cardiac Biomarker Screening Underused in Noncardiac Surgery

Batya Swift Yasgur, MA, LSW

December 17, 2020

Despite its potential to reduce mortality, perioperative biomarker screening to reduce the risk of myocardial injury after noncardiac surgery (MINS) is underutilized, according to a new study.

Investigators analyzed data on close to 60,000 patients who had undergone noncardiac surgery in Alberta, Canada, between January 2013 and December 2017.

They found that only about 7% underwent preoperative natriuretic peptide screening. And only about 20% had postoperative troponin levels measured.

In patients whose screening found preoperative biomarker elevation, 6-month mortality, hospitalizations for heart failure (HF), and acute coronary syndromes (ACS) were increased.

"The first step in improving outcomes in patients with MINS is identifying them in the first place," senior author Michelle Graham, MD, professor of medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada, told | Medscape Cardiology.

"This can be done in all eligible patients postoperatively, but implementing preoperative screening with BNP [brain natriuretic peptide] can identify those who need monitoring the most, and resources can be targeted at these patients," she said.

"Robust Approach"

Graham explained that worldwide, 312 million noncardiac surgeries are performed annually, with 5 million to 10 million patients experiencing a perioperative cardiac event.

Approximately 10% of patients with MINS die within 30 days and, "in fact, there is a dose-graded response in mortality and time to death with increasing levels of postoperative troponin elevations," she said.

The traditional tool for stratifying noncardiac patients at risk for MINS is the Revised Cardiac Risk Index (RCRI), although numerous guidelines recommend perioperative cardiac biomarker screening in high-risk patients — including BNP or N-terminal pro-BNP (NT-proBNP). The current study, designed to investigate whether these recommendations are indeed being implemented, looked at 59,506 patients in Alberta who underwent noncardiac surgery between 2013 and 2017 and had an overnight hospital stay.

Patients were required to be at least age 65 years with an RCRI score of at least 1 or age 45 to 64 years with a history of cardiovascular disease.

Their mean age was 68.4 years, 55% were female, and 30% had a history of ischemic heart disease.

Missed Opportunities

The rate of natriuretic peptide screening was 6.8%, with 3277 patients screened with BNP and 1455 with NT-proBNP.

When the researchers stratified recipients of biomarker screening by RCRI score, they found that screening ranged from 4.1% to 30.1%.

Over the course of the study period, rates of preoperative natriuretic peptide screening increased "marginally," from 6.2% in 2013-2015 to 7.8% in 2016-2017.

Only 19.5% of patients had their troponin levels measured at least once during their admission and, of these, 4.7% had an elevated troponin. Of the 11,619 patients who underwent postoperative troponin monitoring, MINS was detected in 24%.

Of the patients with an elevated preoperative natriuretic peptide level, only 33.2% received any postoperative troponin monitoring, although rates increased from 31.3% in 2013-2015 to 36.1% in 2016-2017.

During the 6-month follow-up period, 7.1% of the cohort died, 6.2% were admitted to the hospital for ACS, and 6.0% were admitted for heart failure. In particular, patients with elevated perioperative screening biomarkers had increased 6-month mortality, as well as more hospitalizations for HF and ACS, compared with those without elevated biomarkers.




P value

Natriuretic peptide level

Mortality: 9.8%

HF admission: 5.7%

ACS: 13.9%

Mortality: 16.4%

HF admission: 26.2%

ACS: 7.7%

< .0001


Mortality: 7.8%

HF admission: 6.8%

ACS: 6.8%

Mortality: 12.7%

HF admission: 10.7%

ACS: 16.1%

< .0001

"From the moment a patient is accepted for surgery, there might be multiple missed opportunities to promote perioperative screening," the authors comment in the study, which was published online December 9 in the Canadian Journal of Cardiology.

"Risk stratification starts with higher RCRI score [and] our study has shown that patients with higher RCRI score are more likely to receive preoperative biomarker screening" they note. However, the remaining patients "might not have been referred for a formal preoperative assessment or were potentially misclassified as low-risk."

Graham added that screening might be underutilized because "translating clinical research and guideline recommendations to demonstrable changes in clinical practice has always been a challenging endeavor."

Education and Collaboration

Commenting on the study for | Medscape Cardiology, Joel Parlow, MD, professor, Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada, said it "illustrates the difficulty in bringing evidence-based recommendations into widespread practice."

Parlow, who is the coauthor of an accompanying editorial and was not involved with the study, stated that without the "sort of large-scale and detailed data analyzed by the authors, there is no way to know whether patients are receiving the potential benefits that are possible by following practice guidelines."

He noted that a "planned implementation strategy, specifically addressing the barriers to knowledge translation, is necessary to ensure that evidence is put into practice."

Moreover, "wide education of all stakeholders and collaboration between the different groups of healthcare providers involved in the care of surgical patients are key components," Parlow said.

The study and editorial authors have disclosed no relevant financial relationships.

Can J. Cardiol. Published online December 9, 2020. Abstract, Editorial

For more Medscape Cardiology news, join us on Facebook and Twitter.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.