Highlights
Peri-operative myocardial infarction/injury (PMI) remains one of the most important and often under-recognized cardiac complications after non-cardiac surgery. In a large multicentre prospective cohort of high-risk surgical patients, postoperative cardiologist evaluation was associated with a substantially lower risk of major adverse cardiac events and all-cause death at 365 days.
The study is notable because access to cardiology was not randomly assigned; instead, it varied for operational reasons such as weekend staffing constraints and competing clinical priorities. That “natural variation” created a real-world comparison that suggests specialist involvement may improve outcomes through more frequent diagnostic testing and more guideline-concordant medical therapy.
The findings support a multidisciplinary approach to postoperative PMI surveillance and management, while also highlighting the need for randomized studies to confirm causality and define which patients benefit most.
Background and Clinical Context
Myocardial injury after non-cardiac surgery is common, prognostically important, and frequently clinically silent. Many affected patients do not present with classic ischemic chest pain; instead, they are detected through active surveillance with postoperative troponin measurements. This matters because even small troponin elevations after surgery are associated with later cardiovascular events and mortality.
Despite this risk, the management of PMI has been heterogeneous across institutions. Surgical patients are often recovering from anesthesia, pain, bleeding risk, hypotension, anemia, or infection, which can obscure cardiac symptoms and complicate treatment decisions. Clinicians must balance ischemic risk against postoperative bleeding, wound-healing concerns, hemodynamic instability, and the need for urgent non-cardiac care.
In this setting, cardiologist evaluation may help by clarifying the likely mechanism of injury, distinguishing type 1 myocardial infarction from demand-related injury, recommending targeted imaging or monitoring, and optimizing secondary prevention therapies. However, until now, it has remained uncertain whether specialist involvement translates into better outcomes rather than simply reflecting referral of sicker or more complex patients.
Study Design
This multicentre, prospective study included 14 294 high-risk patients undergoing non-cardiac surgery who were eligible for an institutional PMI active surveillance and response programme. Among them, 1048 developed PMI and were included in the present analysis.
Cardiologist evaluation after surgery was inconsistently available because of staffing limitations, including weekends, public holidays, and situations in which more urgent patients had to be prioritized. This pragmatic variability allowed comparison between patients who received postoperative cardiologist evaluation and those who did not.
The primary endpoint was major adverse cardiac events (MACE), defined as a composite of cardiovascular death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 365 days. The secondary endpoint was all-cause death at 365 days. The investigators used Cox proportional hazards models to estimate the association between cardiologist evaluation and outcomes, with adjustment for confounding factors.
Key Findings
Of the 1048 patients with PMI, 614 (58.6%) received postoperative cardiologist evaluation. Baseline characteristics were broadly similar between groups, which strengthens the interpretability of the comparison, although residual confounding cannot be excluded in an observational design.
After adjustment, cardiologist evaluation was independently associated with a lower risk of MACE at 365 days, with an adjusted hazard ratio (aHR) of 0.54 and a P value of .001. This corresponds to an approximately 46% relative reduction in the risk of the composite cardiovascular outcome among patients who were seen by a cardiologist.
Cardiologist evaluation was also associated with lower all-cause mortality at 365 days, with an aHR of 0.65 and a P value of .037. In practical terms, this suggests a 35% relative reduction in death from any cause over the year after surgery among evaluated patients.
Sensitivity analyses supported the main findings, which adds credibility to the results and reduces concern that the association was driven by one specific analytic choice. The study also showed important differences in downstream care: patients who saw a cardiologist were more likely to undergo non-invasive cardiac imaging and more likely to receive dual antiplatelet therapy and statin therapy.
These process-of-care differences are clinically plausible as mediators of improved outcomes. Non-invasive imaging may help refine diagnosis and risk stratification, while statins and antiplatelet therapy may reduce recurrent ischemic events in appropriately selected patients. At the same time, the benefit likely reflects not a single intervention, but a bundle of specialist-driven decisions, including closer follow-up, better diagnostic clarification, and more deliberate secondary prevention.
Selected Results at a Glance
Patients with PMI analyzed: 1048
Received cardiologist evaluation: 614 (58.6%)
Primary outcome, MACE at 365 days: aHR 0.54; P = .001
Secondary outcome, all-cause death at 365 days: aHR 0.65; P = .037
More frequent with cardiology evaluation: non-invasive cardiac imaging, dual antiplatelet therapy, statin therapy
Expert Commentary
This study addresses a clinically important and common gap in peri-operative care: once PMI is detected, what is the best next step? The findings suggest that cardiology involvement is not merely a “luxury consultation” but may be associated with meaningful improvements in long-term outcomes for high-risk surgical patients.
Several features strengthen the study. First, it was multicentre and prospective, limiting some of the biases that often affect retrospective registry analyses. Second, the comparator arose from staffing constraints rather than deliberate triage based on prognosis alone, creating a quasi-pragmatic comparison. Third, the investigators assessed clinically meaningful endpoints at 1 year, not just short-term biomarker changes.
Nevertheless, caution is essential. This is an observational association, not proof of causation. Patients who were evaluated by cardiologists may have differed in unmeasured ways, such as peri-operative stability, access to follow-up, or institutional workflow. In addition, the analysis does not isolate which cardiology actions were most beneficial. The apparent benefit may derive from earlier recognition of true myocardial infarction, better optimization of heart failure therapy, more appropriate antithrombotic decisions, or improved coordination of care after discharge.
Generalizability is also a consideration. The study focused on high-risk patients managed within an active surveillance program, which may not reflect hospitals without routine postoperative troponin screening. In centers where PMI is not actively sought, the first challenge is detection; in centers that do screen, the next challenge is ensuring timely expert response.
The work aligns with broader peri-operative guidance emphasizing surveillance, risk stratification, and individualized management. It also reinforces an emerging view that PMI should not be dismissed as a transient laboratory abnormality. Even when the injury is clinically silent, it often signals substantial cardiovascular risk that deserves structured follow-up.
From a practice standpoint, this study supports building pathways that ensure rapid specialist review for postoperative troponin elevations in high-risk patients. A reasonable model would include confirmation of the diagnosis, assessment for ischemia or hemodynamic triggers, echocardiography or other imaging when indicated, medication optimization, and clear outpatient follow-up after discharge. Importantly, treatment must be balanced against postoperative bleeding risk and surgical considerations.
Conclusion
In high-risk patients who develop peri-operative myocardial infarction/injury after non-cardiac surgery, postoperative cardiologist evaluation was associated with fewer major adverse cardiac events and lower all-cause mortality at 365 days. The results support interdisciplinary postoperative management and suggest that structured cardiology involvement may improve outcomes after PMI.
However, because the evidence is observational, randomized or carefully designed implementation studies are still needed to determine causality, identify the most effective components of specialist care, and define how best to integrate cardiology consultation into peri-operative pathways across diverse hospital settings.
Funding and Clinical Trial Registration
Funding information and clinicaltrials.gov registration were not provided in the source summary. Readers should consult the full article for complete disclosures.
References
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