The Expert Consensus’ corresponding author is Dr. Liu Kexuan, a prominent figure in Chinese anesthesiology. Dr. Liu is the Dean of the School of Anesthesiology at Southern Medical University and the Director of the Anesthesia Surgery Center of Southern Hospital. His national leadership roles include serving as a Chief Scientist of the National Key Research and Development Program and the Deputy Chairman of the Anesthesiology Branch of the Chinese Medical Association. A recipient of the Guangdong Science and Technology Progress First Prize , he is also a “Pearl River Scholar” Distinguished Professor.
This article summarizes the 2025 “Expert Consensus on the Perioperative Use of Cardiac Biomarkers in Noncardiac Surgery,” [1] providing clinicians with actionable recommendations for risk stratification, diagnosis, and management of cardiovascular events.
The Evolving Role of Biomarkers in Perioperative Cardiovascular Risk
Cardiovascular events are a leading cause of postoperative mortality in major noncardiac surgery. Cardiac biomarkers offer an objective window into a patient’s cardiac status, moving beyond traditional clinical risk indices to provide dynamic, real-time physiological data. This consensus, developed by experts in anesthesiology, cardiology, and laboratory medicine, provides a clear framework for integrating these powerful tools into daily clinical practice to improve patient safety and outcomes.
Preoperative Risk Stratification: Who and How to Test
Effective perioperative management begins with accurate risk assessment. The consensus provides clear guidance on leveraging biomarkers before the patient enters the operating room.
Choosing the Right Biomarkers
The foundational recommendation is the adoption of high-sensitivity cardiac troponin (hs-cTn) over conventional cTn assays. Conventional troponin lacks the sensitivity to identify many at-risk patients, often misclassifying them as low-risk. In contrast, hs-cTn can detect minute levels of myocardial injury, significantly improving the correct classification of patients and predicting both short- and long-term mortality and major adverse cardiovascular events (MACE) [2].
Alongside hs-cTn, brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are recommended as powerful predictors of postoperative MACE. These markers of myocardial wall stress and hs-cTn, a marker of injury, provide complementary information. When used in combination, they significantly enhance the accuracy of risk stratification beyond what clinical risk scores like the RCRI can provide alone [3,4,5]. Other novel biomarkers like GDF-15 and sST-2 show promise but currently lack sufficient evidence for routine recommendation.
Identifying Patients for Preoperative Screening
Routine screening for all patients is not recommended. Instead, testing should be targeted at those most likely to benefit. The consensus advises preoperative hs-cTn and BNP/NT-proBNP testing for patients undergoing intermediate- or high-risk noncardiac surgery who meet one or more of the following criteria [6,7,8,9]:
- Pre-existing cardiovascular disease
- Multiple cardiovascular risk factors (including age ≥65)
- Cardiovascular signs or symptoms
- Poor functional capacity (<4 METs)
For emergency surgeries, biomarker testing should not delay the procedure. However, if conditions like acute coronary syndrome or acute heart failure are suspected, testing should be completed if possible, and close postoperative follow-up is essential.
Table 1: Risk Classification of Non-Cardiac Surgeries [8]
| Risk category | Risk | Type of surgery |
|---|---|---|
| Low risk | <1% | Breast, dental, thyroid, ophthalmology, minor gynecological surgery, minor orthopedic surgery (such as meniscectomy), plastic surgery, superficial surgery, minor urological surgery (such as transurethral prostate resection), thoracoscopic limited lung resection. |
| Intermediate risk | 1%~5% | Carotid endarterectomy, carotid endarterectomy or carotid stenting for asymptomatic patients, carotid endarterectomy for symptomatic patients, endovascular aneurysm repair, head and neck surgery, splenectomy, esophageal hiatal hernia repair, cholecystectomy, and other abdominal surgeries, non-major thoracic surgery, major neurosurgical or orthopedic surgery (such as spine and hip surgeries), peripheral angiography, kidney transplant surgery, major urological or gynecological surgery. |
| High risk | >5% | Adrenalectomy, aortic and major vascular surgery, carotid stenting for symptomatic patients, pancreaticoduodenectomy, liver resection, bile duct surgery, esophagectomy, revascularization or amputation surgery for acute ischemia of the lower limbs, total pneumonectomy (thoracoscopic or open chest surgery), lung or liver transplant, intestinal perforation repair, total cystectomy. |
Postoperative Surveillance: Detecting Silent Myocardial Injury
A significant portion of postoperative myocardial events are clinically silent, lacking typical symptoms like chest pain. Systematic biomarker surveillance is therefore key to early detection.
Diagnosing Myocardial Injury After Noncardiac Surgery
The consensus endorses the 4th Universal Definition of Myocardial Infarction for diagnosing postoperative myocardial injury and infarction [14]. Myocardial injury is defined as a cTn/hs-cTn level above the 99th percentile upper reference limit, with an acute injury distinguished by a dynamic change from the baseline value. This diagnosis is critical, as even asymptomatic troponin elevation is strongly associated with increased 30-day mortality [15,16].
Who to Screen and When
Postoperative hs-cTn screening should be performed in the same high-risk populations identified for preoperative testing. Specifically, patients with elevated preoperative BNP/NT-proBNP or hs-cTn levels are prime candidates for postoperative surveillance. The crucial window for detection is within the first three days, as most events occur within 48 hours [13,17,18,19]. The recommendation is for daily hs-cTn testing for the first 48 to 72 hours after intermediate- or high-risk surgery in these at-risk individuals [7,8,10].
Translating Biomarker Data into Clinical Action
Detecting an abnormal biomarker level is only the first step. The true value lies in using this information to guide patient management.
Managing Elevated Preoperative Biomarkers
An elevated preoperative hs-cTn or BNP/NT-proBNP level identifies a high-risk patient who requires heightened vigilance. Recommended actions include:
- Adhering strictly to perioperative guidelines (e.g., avoiding hypotension, managing blood glucose, correcting anemia).
- Enhancing postoperative monitoring.
- Consulting with a cardiovascular specialist to assess the need for further non-invasive testing or optimization before surgery.
Importantly, the consensus does not recommend routinely initiating preventative medications like beta-blockers, aspirin, or clonidine based solely on an elevated biomarker, as evidence from large trials has shown a lack of benefit and potential for harm [20,21,22].
Managing Postoperative Myocardial Injury
When postoperative surveillance reveals myocardial injury, a multidisciplinary approach is crucial to determine the underlying cause (e.g., type 1 vs. type 2 MI, sepsis, pulmonary embolism) [23]. This involves a comprehensive review of the patient’s clinical status, ECG, and imaging studies.
While evidence is still evolving, recent studies suggest that initiating secondary prevention therapies can improve long-term outcomes for myocardial injury patients. The consensus suggests considering the initiation of:
- Aspirin therapy [13]
- Statin therapy [13]
- Anticoagulation (as demonstrated in the MANAGE trial with dabigatran) [11]
These interventions may reduce the risk of future major vascular events and mortality, transforming myocardial injury from a prognostic marker into a treatable condition [12].
Expert Consensus on Perioperative Use of Cardiac Biomarkers in Noncardiac Surgery (2025 edition) Recommendations
Annex: Recommendations from the Expert Consensus on Perioperative Use of Cardiac Biomarkers in Noncardiac Surgery (2025 edition)
Recommendation 1
Use hs-cTn rather than conventional cTn for cardiovascular risk assessment before non-cardiac surgery.
Recommendation 2
Patients with concurrent cardiovascular disease, cardiovascular risk factors, or clinical manifestations of cardiovascular disease undergo hs-cTn testing before undergoing medium- to high-risk non-cardiac surgery.
Recommendation 3
For patients with acute or chronic coronary syndrome planning to undergo non-cardiac surgery, if clinical symptoms, electrocardiogram abnormalities, elevated cTn/hs-cTn levels, or poor exercise tolerance are present, it is recommended to consider additional transthoracic echocardiography or stress myocardial perfusion imaging. For patients who may have extensive ischemia or an unstable clinical condition, coronary angiography is recommended.
Recommendation 4
For patients requiring emergency surgery, the operation should not be delayed for cTn/hs-cTn testing or cardiovascular risk assessment. However, postoperative close monitoring and management of cardiovascular disease are necessary. If possible, a consultation with a cardiovascular specialist should be arranged to provide recommendations for perioperative management of cardiovascular diseases.
Recommendation 5
For patients requiring emergency surgery, it is recommended to perform a comprehensive cardiovascular risk assessment, including cTn/hs-cTn testing, only if the medical history or physical examination suggests the presence of acute heart failure, acute coronary syndrome, severe obstructive heart disease (such as severe valvular stenosis or left ventricular outflow tract obstruction), or severe pulmonary hypertension before surgery.
Recommendation 6
BNP/NT-proBNP can be used for cardiovascular risk assessment before non-cardiac surgery
Recommendation 7
It is recommended that patients with concurrent cardiovascular disease, cardiovascular risk factors, or clinical manifestations of cardiovascular disease undergo BNP/NT-proBNP testing before undergoing medium- to high-risk non-cardiac surgery.
Recommendation 8
Combining hs-cTn and BNP/NT-proBNP testing can improve the accuracy of cardiovascular risk assessment before non-cardiac surgery.
Recommendation 9
Preoperative assessment of cardiac enzymes or other biomarkers is not recommended for
cardiovascular risk stratification in patients undergoing noncardiac surgery.
Recommendation 10
For non-cardiac surgery patients, the diagnosis of perioperative myocardial injury and myocardial infarction should adhere to the 4th Universal Definition of Myocardial Infarction
Recommendation 11
It is recommended that patients with elevated preoperative BNP/NT-proBNP or hs-cTn levels, concurrent cardiovascular disease, cardiovascular risk factors, or clinical manifestations of cardiovascular disease undergo routine postoperative cTn/hs-cTn testing after medium- to high-risk non-cardiac surgery.
Recommendation 12
Postoperative cTn/hs-cTn testing should be conducted daily within the first 48 to 72 hours following surgery
Recommendation 13
For patients with elevated postoperative cTn/hs-cTn levels, a comprehensive assessment should be conducted by considering preoperative cTn/hs-cTn levels, clinical symptoms and signs, electrocardiogram (ECG) findings, and echocardiography results. This approach will help promptly identify the cause of the elevated postoperative cTn/hs-cTn levels.
Recommendation 14
The diagnosis of postoperative heart failure should follow the diagnostic criteria for acute heart failure as outlined in the 2023 European Society of Cardiology (ESC) guidelines for the management of acute and chronic heart failure.
Recommendation 15
For suspected postoperative heart failure, it is recommended to perform BNP/NT-proBNP testing
Recommendation 16
For patients with elevated preoperative BNP/NT-proBNP or hs-cTn levels, close attention should be paid to the risk of perioperative cardiovascular events. Measures recommended in the perioperative cardiovascular risk assessment and management guidelines for non-cardiac surgery should be taken to prevent perioperative cardiovascular events.
Recommendation 17
For patients with elevated preoperative BNP/NT-proBNP or hs-cTn levels, it is recommended to seek assistance from a cardiovascular specialist to assess the necessity for further cardiovascular diagnostic tests.
Recommendation 18
For patients diagnosed with postoperative myocardial injury, it is advisable to consider a multidisciplinary consultation to determine the underlying cause and devise targeted treatment strategies
Recommendation 19
For patients diagnosed with postoperative myocardial injury, it may be considered to initiate treatment with aspirin, statins, or anticoagulants to reduce the long-term risk of cardiovascular and cerebrovascular events.
