Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group

Figures & data

Figure 1. Conceptualisation of the definitions of myocardial infarction and myocardial injury.

Footnote: ^aType 1 MI: Caused by coronary artery disease and precipitated by plaque disruption (rupture or erosion); ^bType 2 MI: Ischaemic myocardial injury caused by a mismatch between oxygen supply and demand.

Figure 2. Example of a potential perioperative cTn screening and management pathway.

Footnote: Algorithm published in European Journal of Anaesthesia by Puelacher et al. [20]. (a) Details the perioperative screening pathway, including how to define high risk patients. (b) Depicts a perioperative management and care pathway.

*Known significant cardiovascular disease, such as coronary artery disease, cerebral vascular disease, peripheral arterial disease, congestive heart failure.

^†Preoperative cTn may provide information for risk stratification, but it is mainly necessary as a baseline value for perioperative myocardial injury screening.

cTn: cardiac troponin; ECG: electrocardiogram; hs: high-sensitivity; RCRI: Revised Cardiac Risk Index

Table 1. Proposed changes to the Puelacher et al. [20] EJA algorithm recommendations by the expert panel.

Puelacher et al. EJA algorithm [20]	Proposed changes by the expert panel
High-risk patients undergoing non-cardiac surgery are defined as those aged ≥45 years with known significant cardiovascular disease (e.g. CAD, cerebral vascular disease, peripheral arterial disease or congestive heart failure); OR patients aged >45 years with a RCRI score ≥1; OR patients aged 18–64 years with significant cardiovascular disease who are scheduled for urgent/emergent or semi-urgent surgery; OR aged ≥65 years	Patients undergoing urgent or emergent surgery should be considered for PMI screening only if they are aged ≥50 years with cardiovascular risk factors or with established cardiovascular disease
Postoperative hs-cTn measurements should be taken on postoperative Day 1, Day 2 and Day 3 (48–72 h after surgery)	In primary and secondary care, hs-cTn measurements should be taken on postoperative Day 1 and Day 2 In tertiary care, only one postoperative hs-cTn measurement is required during routine clinical practice on postoperative Day 1 (or Day 2 if not feasible)

CAD: coronary artery disease; EJA: European Journal of Anaesthesia; hs-cTn: high-sensitivity cardiac troponin; PMI: perioperative myocardial injury; RCRI: Revised Cardiac Risk Index.

Puelacher C, Bollen Pinto B, Mills NL, et al. Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: a literature review with expert consensus. Eur J Anaesthesiol. 2021;38(6):600–608.

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