Interpreting troponin elevation after surgery: diagnostic challenges and a pragmatic approach

Introduction: Cardiac troponin is a highly sensitive marker of myocardial injury, although its interpretation after non-cardiac surgery remains challenging. Postoperative troponin elevation is common, frequently asymptomatic and associated with a markedly increased risk of short-term mortality, yet it is often misinterpreted or overlooked in surgical practice.

Methods: We performed a narrative review of contemporary evidence and international guidelines addressing perioperative troponin measurement, myocardial injury after non-cardiac surgery (MINS), and perioperative myocardial infarction (MI), with a focus on their relevance to surgical teams. MEDLINE and Embase were searched for adult English-language studies, prioritising the past 10–15 years and key consensus statements. Studies relevant to postoperative outcomes, risk stratification and management were synthesised into a pragmatic stepwise approach for surgical teams.

Findings: Studies including VISION and POISE demonstrate that even modest postoperative troponin rises are independently associated with substantially increased 30-day mortality, most often in the absence of ischaemic symptoms. Differentiating type 1 MI, type 2 MI and non-ischaemic myocardial injury is difficult in the perioperative setting because clinical features, electrocardiography and baseline troponin values are frequently non-specific. Contemporary European and North American guidelines now support targeted perioperative troponin surveillance in high-risk patients to allow early detection and risk stratification.

Conclusions: Postoperative troponin elevation represents a powerful prognostic marker rather than a single disease entity. A structured, stepwise approach incorporating preoperative risk assessment, serial troponin measurement, clinical correlation and selective imaging can help surgical teams distinguish clinically significant myocardial injury from chronic or non-ischaemic elevation, enabling timely multidisciplinary management and potentially improving outcomes.