Rethinking cardiac risk reduction after noncardiac surgery: the postoperative Carpe diem

Patients undergoing noncardiac surgery frequently experience major adverse cardiac events. As a significant proportion of these patients develop cardiac complications despite optimal use of preoperative clinical risk-prediction algorithms, physicians have long searched for better methods of forecasting and ameliorating cardiac risk in this population. Recently, postoperative troponin levels have been found to be powerful and independent predictors of cardiovascular mortality in patients undergoing noncardiac surgery. Importantly, the predictive properties of these markers outperform preoperative clinical risk-prediction algorithms. We thus posit that the assessment of postoperative troponin represents an as yet untapped "golden opportunity" for cardiac risk reduction. As cardiac troponin isolates an unusually high-risk subgroup, we outline a strategy that utilizes this marker to improve cardiac outcomes. Where pertinent, strengths and limitations of this approach are discussed and areas of uncertainty identified. As with all hypotheses, this proposition fuels many questions and calls for a research agenda dedicated to quantifying risk or benefit, and defining best practices.