Advances in biomarkers for myocardial injury after non-cardiac surgery

Myocardial injury after non-cardiac surgery (MINS) is a common and clinically important postoperative complication associated with increased short- and long-term mortality. As most cases lack typical ischemic symptoms, diagnosis relies primarily on systematic postoperative biomarker surveillance. Current guidelines recommend serial postoperative measurement of cardiac troponin (cTn) or high-sensitivity cTn, the reference-standard biomarker for myocardial necrosis, in patients at elevated perioperative risk. However, cTn demonstrates limited sensitivity during the early h following myocardial ischemia, underscoring the need for complementary biomarkers capable of detecting ischemic injury before the onset of irreversible myocardial necrosis or troponin elevation. This review summarizes recent advances in emerging circulating biomarkers for early MINS detection, including heart-type fatty acid-binding protein, ischemia-modified albumin, cardiac myosin-binding protein C, copeptin, and other markers reflecting ischemia, necrosis, inflammation, and fibrosis. We critically examine their underlying pathophysiological mechanisms, diagnostic performance, and release kinetics, highlighting their potential to shorten the diagnostic "blind window" associated with conventional biomarkers. The integration of multi-marker panels represents a promising strategy to enhance early diagnostic sensitivity and improve prognostic stratification. Nonetheless, large-scale prospective studies are required to validate their clinical utility and define their role in perioperative decision-making and guideline development.