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A recent morbidity and mortality conference at my institution discussed the care of an elderly patient with multiple comorbidities for a noncardiac surgical procedure. Unfortunately, despite excellent perioperative care, the patient died of a perioperative myocardial infarction (PMI) in the postanesthesia care unit. Hypotension and marked ST segment elevation on the postoperative electrocardiogram left no doubt about the etiology of the patient’s death. However, for the vast majority of patients, the diagnosis of myocardial injury and infarction is not so obvious, and the role of minor elevations in cardiac biomarkers is unclear. In this issue of ANESTHESIOLOGY, Levy et al. examine the value of creatine kinase MB-fraction and cardiac troponin (cTn) as independent predictors of all-cause mortality or a major cardiovascular event over the year after surgery. The meta-analysis focuses on patients undergoing noncardiac surgery with outcomes assessed by adjudicators blinded to cardiac biomarker values. They show that an increased postoperative creatine kinase MB-fraction or cTn is associated with a sixfold increased risk of death in the first year after surgery. Complicating the matter, however, is that only 14% of patients who experience a PMI will have chest pain, and only 53% of patients will have clinical signs or symptoms. That leaves a large group of patients with asymptomatic PMI who are at an increased risk of earlier mortality. This lack of symptoms in the postoperative patient is the crux of the problem and begs the important questions: Should we be testing asymptomatic postoperative patients for cardiac biomarker release? If the answer is no, then is there a patient risk index that indicates when such a level of increased vigilance is warranted? What level of biomarker release warrants patient intervention? What investigations or therapies should be initiated if there is an abnormal result? And, even more problematic, what should we tell the patient and family about a normal or abnormal result? The Joint Task Force of the European Society of Cardiology/American College of Cardiology for the Redefinition of Myocardial Infarction still defines PMI as a combination of symptoms, electrocardiogram changes, and biomarker elevation. Yet, most patients with increased postoperative cardiac biomarkers experience myocardial infarction, regardless of electrocardiogram changes or symptomatology, which, in the presence of residual anesthesia, analgesics, and possible intubation with sedation, is not surprising. More important, state-of-the-art biomarkers are able to detect muscle damage earlier and with sensitivity down to the detection of a single molecule of troponin.

If a Troponin Falls in a Forest but No One Measures It, Does It Really Matter?