Percentage of patients with cardiac risk where troponin levels were assessed postoperatively.

Cardiovascular complications remain a significant contributor to postoperative mortality. Recent studies report a 12-18% incidence of troponin elevation after surgery, however, the majority of patients with biomarker elevations do not experience any symptoms. Troponin elevation with or without symptoms was significantly associated with 30-day mortality.² The American College of Cardiology and the American Heart Association released a scientific statement on Myocardial Injury after Non-cardiac Surgery (MINS) recommending troponin surveillance on high-risk patients undergoing non-cardiac surgery (NCS) for the first 48-72 hours while hospitalized.⁴  European guidelines recommend preoperative assessment of troponin and b-type natriuretic (BNP) before NCS (Grade I) as well as postoperative monitoring for patients with known CVD or CV risk factors.³ The optimal management of MINS remains uncertain.⁵  However, a recent study found that patients undergoing vascular surgery at hospitals with higher postoperative troponin testing rates experienced fewer adverse outcomes than patients who had surgery at hospitals with lower testing requirements.⁶ Recent studies support monitoring troponin levels before surgery and 2-3 days postoperatively for moderate to high-risk patients.⁷ Over 90% of 30-day myocardial injuries occur within the first 2 days of surgery.⁷

Anesthesia End to 72 hours after Anesthesia End

• Adult patients > 65 years undergoing high-risk non-cardiac surgery*
• Adult patient > 45 years with a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes requiring preoperative insulin, or chronic kidney disease (baseline Cr > 2.0 mg/dL) and undergoing high-risk surgery*

*High risk surgeries include intraperitoneal, intrathoracic, or supra-inguinal vascular procedures, as adapted from the Revised Cardiac Risk Index (RCRI) and identified by Anesthesia CPT codes:

** Comorbidities posing high cardiac risk are adapted from the Revised Cardiac Risk Index (RCRI) and are identified by Elixhauser Comorbidity Index variables (congestive heart failure, diabetes), preoperative lab values (baseline serum creatinine), or comorbidity-specific ICD-9/10 codes (ischemic heart disease, cerebrovascular disease):

• ASA 5 & 6 including organ procurement (CPT: 01990)
• Cardiac cases as determined by Procedure Type: Cardiac (value codes > 0)
• Outpatient cases

Any troponin I or troponin T value documented within 72 hours after Anesthesia End.

• If no troponin I (or troponin T) values are found within 72 hours after Anesthesia End, the case will be flagged.

*This measure will include only valid MPOG cases as defined by the Is Valid Case phenotype.

Pending.

Primary Provider - Anesthesia provider(s) present for the longest duration of the case per staff role.

Algorithm for determining Provider Sign-In Duration:

• Start
  • Patient in Room. If not available, then
  • Induction End. If not available, then
  • Anesthesia Start
• End
  • Patient Out of Room. If not available, then
  • Anesthesia End

1. Smilowitz NR, Gupta N, Ramakrishna H, Guo Y, Berger JS, Bangalore S. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. JAMA Cardiol. 2017 Feb 1; PMID:, 2(2):181-187. doi: 10.1001/jamacardio.2016.4792.
2. Writing Committee for the VISION Study Investigators; Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, Walsh M, Abraham V, Pearse R, Wang CY, Sessler DI, Kurz A, Szczeklik W, Berwanger O, Villar JC, Malaga G, Garg AX, Chow CK, Ackland G, Patel A, Borges FK, Belley-Cote EP, Duceppe E, Spence J, Tandon V, Williams C, Sapsford RJ, Polanczyk CA, Tiboni M, Alonso-Coello P, Faruqui A, Heels-Ansdell D, Lamy A, Whitlock R, LeManach Y, Roshanov PS, McGillion M, Kavsak P, McQueen MJ, Thabane L, Rodseth RN, Buse GAL, Bhandari M, Garutti I, Jacka MJ, Schünemann HJ, Cortes OL, Coriat P, Dvirnik N, Botto F, Pettit S, Jaffe AS, Guyatt GH. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017 Apr 25;317(16):1642-1651. doi: 10.1001/jama.2017.4360. PMID: 28444280.
3. Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K; ESC Scientific Document Group. Linee guida ESC 2022 per la valutazione cardiovascolare e la gestione dei pazienti sottoposti a chirurgia non cardiaca elaborate dalla task force per la valutazione cardiovascolare e la gestione dei pazienti sottoposti a chirurgia non cardiaca della Società Europea di Cardiologia (ESC) con il patrocinio della European Society of Anaesthesiology and Intensive Care (ESAIC) [2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery Developed by the task force for cardiovascular assessment and Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC)]. G Ital Cardiol (Rome). 2023 Jan;24(1 Suppl 1):e1-e102. Italian. doi: 10.1714/3956.39326. PMID: 36645369.
4. Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation. 2021 Nov 9;144(19):e287-e305. doi: 10.1161/CIR.0000000000001024. Epub 2021 Oct 4. PMID: 34601955.
5. Chen JF, Smilowitz NR, Kim JT, Cuff G, Boltunova A, Toffey J, Berger JS, Rosenberg A, Kendale S. Medical therapy for atherosclerotic cardiovascular disease in patients with myocardial injury after non-cardiac surgery. Int J Cardiol. 2019 Mar 15;279:1-5. doi: 10.1016/j.ijcard.2018.12.032. Epub 2018 Dec 12. PMID: 30598249; PMCID: PMC6358460.
6. Azizi PM, Wijeysundera DN, Wijeysundera HC, Austin PC, Jerath A, Kayssi A, Ko DT. Association Between Hospital Postoperative Troponin Use and Patient Outcomes After Vascular Surgery. Anesth Analg. 2023 Sep 1;137(3):629-637. doi: 10.1213/ANE.0000000000006411. Epub 2023 Mar 8. PMID: 36913232.
7.  Sessler DI, Al Jarkas A: Postoperative Mortality - And How to Prevent It 2024 doi:10.1016/s0735-1097\(20\)30737-3 

Next Review: 2028

Published Date: 02/2025