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Points à retenir
1. Examiner la justification et les données probantes à
l’appui de l’utilisation de biomarqueurs périopératoires
(BNP/NTproBNP et troponine).
2. Explorer trois modèles uniques pour l’intégration de
biomarqueurs périopératoires dans la pratique.
3. Appliquer des principes directeurs pour réaliser une
évaluation propre au site de l’approche actuelle en
matière d’évaluation des risques périopératoires et
examiner les stratégies sur la manière d’entreprendre
la mise en œuvre d’un programme de dépistage
périopératoire de biomarqueurs.
4. Comprendre les défis couramment affrontés et les
solutions proposées pour la mise en œuvre d’un
programme de dépistage périopératoire de biomarqueurs.
5. Prendre la mesure du rôle potentiel d’un modèle de
partage des soins pour faciliter le dépistage et la prise en
charge de biomarqueurs périopératoires.
Over 300 million adults worldwide undergo noncardiac
surgery annually,
1
and over 10 million patients will suffer a
major cardiac complication.
2
The magnitude of this problem is
likely to increase due to an aging population, an increase in the
prevalence of cardiovascular disease, and a trend toward more
surgical interventions in elderly patients.
The 2014 American College of Cardiology (ACC) and American
Heart Association (AHA) noncardiac surgery guidelines encourage
the use of postoperative ECG and troponin in the setting of signs
or symptoms of ischemia, stating that the usefulness of routine
postoperative screening is uncertain in the absence of established
risk and benefits of a defined management strategy.
3
There is no
mention of preoperative risk assessment using brain natriuretic
peptide (BNP) or N-terminal pro-BNP-type natriuretic peptide
(NTproBNP). In contrast, the European Society of Cardiology
and European Society of Anesthesiology, also published in 2014,
notes that preoperative BNP/NTproBNP levels have prognostic
value for cardiac events after major noncardiac vascular surgery
and suggest testing of cardiac troponin in high-risk patients, both
before and 48–72 h after major surgery.
4
More recently, the 2017
Canadian Cardiovascular Society (CCS) perioperative guidelines
recommend the use of perioperative biomarkers including
preoperative BNP/NTproBNP testing to identify patients at a
How to Set Up a Perioperative BNP/NTproBNP
and Troponin Screening Program
Erin N. Sloan, MD, Erin E. Morley, MD, FRCPC
The Division of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
Corresponding author: ensloan@gmail.com
Submitted: November 9, 2020. Accepted: January 18, 2021. Published: March 16, 2020. DOI: 1022374/cjgim.v16iSP1.531.
Key Learning Points
1. Review the rationale and evidence to support the use of perioperative biomarkers (BNP/
NTproBNP and troponin)
2. Explore three unique models for integrating perioperative biomarkers into practice
3. Apply guiding principles to perform a site-specific assessment of the current approach to
perioperative risk assessment and review strategies on how to initiate implementation of
a perioperative biomarker screening program
4. Understand commonly faced challenges, and proposed solutions, for implementing a
perioperative biomarker screening program
5. Appreciate the potential role for a shared-care model to facilitate perioperative
biomarkers screening and management
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higher risk for perioperative adverse cardiac events, and routine
troponin monitoring postoperatively to detect myocardial
ischemia in these higher risk patients.
5
While perioperative
biomarker screening has not been compared to usual care in a
randomized controlled trial (RCT), there is increasing evidence
to support its role in both risk assessment and monitoring of
higher risk patients undergoing noncardiac surgery.
Elevated preoperative levels of BNP/NTproBNP are
strongly associated with vascular death and myocardial injury
after noncardiac surgery (MINS) within 30 days of noncardiac
surgery.
6,7
Although the Revised Cardiac Risk Index (RCRI)
is a widely validated model for cardiac risk stratification,
5,8,9
the addition of preoperative BNP/NTproBNP testing serves to
further refine perioperative cardiovascular risk prediction.
6,7,10
Most MINS events occur within 48 h of surgery, and the
majority of these events are clinically silent. The VISION study
showed that without routine troponin monitoring, 84% of the
MINS events would be undetected.
2
Detecting MINS is clinically
important as, compared to patients without MINS, patients have
an almost ninefold increased risk for major adverse cardiac events
(MACE) and death at 30 days (9.8% vs 1.1%).
2,11
This increased
mortality risk was confirmed in two cohort studies.
12,13
Diagnosis of MINS allows for optimization of medications
and cardiac testing to improve cardiac outcomes.
14–16
An economic
analysis supporting postoperative troponin monitoring is cost-
effective.
17
By comparison, the screening costs for breast or
cervical cancer detection is >10-fold the cost to detect MINS.
Given that patients with MINS are at risk of dying within 30
days, this highlights the importance of screening.
Given considerable variability in Canadian health care
centers with regard to size, staffing, local expertise, rural versus
urban setting, surgical diversity, and volume, it is unlikely that
a single approach for perioperative biomarker screening can
be successfully implemented at every hospital. Three models
successfully being used in British Columbia and Ontario are
highlighted below, along with suggestions on how to overcome
common implementation challenges and a general appraisal tool
that can be tailored to suit one’s unique clinical environment.
The Vancouver General Hospital Model
The Vancouver General Hospital, an academic, tertiary care
referral center for British Columbia and the Yukon Territory, is
the second largest hospital in Canada with 17–19 operating rooms
in use per day. This hospital performs on average 20,000 surgical
procedures annually, of which approximately 70% are inpatient
procedures and approximately 1000 are cardiac surgeries. Nearly
30% of the surgical cases are unscheduled. VGH uses BNP and
troponin I (TnI) but will change to NTproBNP in January 2021
with plans to transition to high-sensitivity troponin T (HSTnT).
In 2015, the Internal Medicine Perioperative Consult Team
(IMPCT) was created. The IMPCT service is staffed by 11 general
internal medicine (GIM) staff physicians with an interest or
expertise in perioperative medicine. In discussion with hospital
administration and surgical and anesthesiology clinicians, the
IMPCT team started with providing shared postoperative care
for all hip fracture patients over age 65, and on a consultation
basis for patients undergoing hepatobiliary, vascular, or major
urological surgery. Initially, to ensure that the IMPCT service
would be financially viable, high-risk patient criteria were
established to identify who would receive consultations. IMPCT
also provided preoperative consultations in the post-anesthesia
care unit (PACU) on two half-days per week.
The service was well received by surgical and anesthesia
colleagues and subsequently expanded to two separate lines of
IMPCT, each comprising a staff internist with one or more GIM
fellows, a GIM resident, and a surgical resident. Preprinted order
sets (PPO) were designed to identify patients appropriate for
preoperative BNP testing (Figure 1) and postoperative troponin
monitoring. The order sets included instructions for “what to do”
and “who to call” if the troponin was elevated (Figure 2). The PPOs
along with a summary of the Canadian Cardiovascular Society
guidelines were presented to the surgical executive committee. Once
approved, each surgical service was offered a dedicated rounds
presentation on perioperative cardiac risk, which also served to field
questions and to elicit feedback specific to each surgical population.
The nurses in the post-anesthesia recovery unit (PACU) and on
the surgical wards are another important stakeholder group and
should be included as they often implement the PPOs.
At present, BNP may be ordered by the surgeon (some have
incorporated into their electronic medical record directly with
routine preoperative blood work), by anesthesia in the PAC (all
BNP results are followed up by the PAC physician lead), or by
the IMPCT team member if the patient is seen preoperatively. An
elevated preoperative BNP (≥92 ng/L) is evaluated in the context
of each patient’s medical history and physical examination. Most
patients with a mild elevation (i.e., BNP of 150 ng/L, asymptomatic,
and satisfactory physical examination in the context of the patient’s
known medical issues) do not require further investigations prior
to surgery. However, as these patients are still at a higher risk of
perioperative MACE, their names are added to the electronic
IMPCT inpatient list to be seen on postoperative day one (or
immediately postoperatively if there are concerns from surgery
or anesthesia). Patients who have an unexpected degree of
elevation in preoperative BNP/NTproBNP (i.e., BNP 400 ng/L,
with no known comorbidities such as established cardiovascular
or renal disease) are scheduled to have a preoperative IMPCT
consultation and may warrant further investigations besides a
clear discussion of perioperative cardiac risk.
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Figure 1. Brain Natriuretic Peptide (BNP) Screening for Non-cardiac Surgery – Pre-op Orders for Inpatients.
Canadian Journal of General Internal Medicine
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Figure 2. Myocardial Injury after Non-cardiac Surgery (MINS) -Post-op Surveillance Orders.
IF YOU RECEIVED THIS FACSIMILE IN ERROR, PLEASE CALL 604-875-4077 IMMEDIATELY
VA: VGH / UBCH / GFS
VC: BP / Purdy / GPC
ORDERS
ADDRESSOGRAPH
COMPLETE OR REVIEW ALLERGY STATUS PRIOR TO WRITING ORDERS
MYOCARDIAL INJURY AFTER NON-CARDIAC SURGERY (MINS) – POST-OP SURVEILLANCE
ORDERS
)deredroebotdetcelesebtsumsexobkcehchtiwsmeti( (Page 1 of 1)
Date: __________________________ Time: __________________________
Pre-operative BNP __________ or NT-proBNP _________
If Pre-operative BNP less than 92 ng/L or NT-proBNP less than 200 ng/L:
no empiric ECG or troponin monitoring required unless otherwise clinically indicated
If Pre-operative BNP 92 ng/L or greater, or NT-proBNP 200 ng/L or greater OR if no preoperative BNP or
NT-proBNP available but patient has one or more of the following:
Age 65 years or older
Coronary artery disease
Heart failure
Creatinine more than 177 micromol/L
Diabetes on Insulin
Stroke or TIA
Undergoing intraperitoneal, intrathoracic, retroperitoneal, or suprainguinal vascular surgery
Then obtain:
ECG on arrival in Post Anesthesia Care Unit (PACU)
Troponin on arrival in PACU & on postoperative days 1, 2 and 3
___________________________ ______________________________ _____________
Prescriber’s Signature Printed Name
VCH.VA.PPO.1044 I Rev.DEC.2020
College ID
Time Processed
RN/LPN Initials
Comments
Notes to Prescriber
If troponin is positive
Order and review ECG, assess patient
Consult Internal Medicine Perioperative Consult Team (IMPCT) if:
Troponin greater than 0.03 but less than 1, and no new ECG changes suggestive
of ischemia (e.g. T-wave inversion, ST depression, ST elevation)
No chest pain
Consult Cardiology if:
Troponin is equal or greater than 1
New ECG changes suggestive of ischemia (e.g. T-wave inversion, ST depression,
ST elevation)
Chest pain
1044
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Page 1A
My
ocardial Injury after Non-Cardiac Surgery (MINS) Surveillance Flow Diagram
BNP less than 92 ng/L
*OR*
NT-proBNP less than 200 ng/L
No empiric ECG or
troponin monitoring
required, perform if
clinically indicated
BNP: 92 ng/L or greater
*OR*
NT-proBNP: 200 ng/L or
greater
No preoperative BNP or NT-proBNP
available, but 1 or more factors of:
Age: 65 years or older
Coronary artery disease
Heart failure
Stroke or TIA
Creatinine:177 micromol/L
or greater
Diabetes on insulin
Undergoing intraperitoneal,
intrathoracic, retroperitoneal,
or suprainguinal vascular
surgery
ECG on arrival to Post Anesthesia Care Unit (PACU)
Troponin on arrival in PACU
Troponin on Postoperative day 1, 2 and 3
If troponin is positive:
Order and review ECG
Assess patient’s clinical status
Troponin greater than 0.03 but less than 1
No new ECG changes suggestive of
ischemia (e.g. T-wave inversion, ST
depression, ST elevation)
No chest pain
Troponin: 1 or greater
New ECG changes suggestive of
ischemia (e.g. T-wave inversion,
ST depression, ST elevation)
Chest pain
Consult Internal Medicine Perioperative
Consult Team (IMPCT)
Consult Cardiology
Preoperative BNP ___________ or NT-proBNP ____________
Figure 2. (Continued)
Postoperatively patients are discharged from the PACU to a
regular surgical ward bed, surgical step-down bed, or the ICU as
appropriate. The surgeon remains the most responsible physician
(MRP). IMPCT provides medical co-management for patients with
complex medical comorbidities and assessment for patients with
elevated postoperative troponin values (ordered based on elevated
preoperative BNP). Via close communication with the surgical team,
for patients with elevated troponin postoperatively, pharmacological
intervention for MINS (i.e., ASA, statin) and/or other strategies to
reduce ischemic burden (i.e., optimization of hemoglobin, fluid
status, hold offending medications) are considered. Cardiology
consultations are reserved for patients who have evidence of active
ischemia (i.e., ischemic symptoms, ischemic ECG changes, or
arbitrarily a TnI of 1.0 or higher, as determined in consensus with
cardiology and as detailed on the PPOs. IMPCT follows inpatients
while acute medical issues exist and can facilitate outpatient follow
up as needed. Overnight calls are managed primarily by the surgical
team with IMPCT support in urgent situations. In house critical
care outreach, or rarely, the internal medicine clinical associate can
provide support overnight as required.
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The COVID-19 pandemic has modified the delivery of
outpatient preoperative assessment. The IMPCT team’s patient
volume is unchanged, but assessment is provided via phone
while anesthesia uses zoom for virtual consultations. A nurse
subsequently contacts patients for COVID-19 screening and
to arrange for blood work (including BNP), and an outpatient
ECG is to be done at the patient’s local lab.
Surgical patient co-management provided by IMPCT has
been an essential part of implementing perioperative biomarker
testing, and this model may confer addition benefits for patients,
colleagues, and budgetary considerations. While co-management
has not shown universal improvement in outcomes,
18
meta-
analyses of shared care by geriatricians and orthopedic surgeons
have showed decreased mortality and shorter length of stay
(LOS).
19,20
Similarly, a meta-analysis of surgical patients with IM
co-management demonstrated decreased LOS and mortality.
18
An RCT looking at co-management by hospitalists and surgeons
versus a consultation care model showed decreased minor, but
not major, complications and fewer discharge delays.
21
Studies
have also shown that shared care models increase prescribing
of evidence-based treatment,
22
increase surgeon and nurse
satisfaction,
21
decrease LOS
19,20,23
, and decrease readmissions
resulting in overall cost savings.
23
The St. Paul’s Hospital Model, Vancouver
St. Paul’s Hospital (SPH) is an academic, tertiary care center and
referral center for British Columbia and the Yukon Territory. With
16 operating rooms are in use per day, this hospital performs over
12,500 surgical cases per year, of which approximately half are
inpatient surgeries and approximately 1250 are cardiac surgeries.
Over 17% of the surgical cases are unscheduled.
The anesthesiologists at SPH initiated guideline-driven
care, in collaboration with internal medicine, by implementing
perioperative biomarker use in accordance with the CCS guidelines.
While an internal medicine inpatient consult service exists, it is
not a dedicated perioperative service. Surgeons or anesthetists
may refer patients to the internal medicine rapid access clinic
for a preoperative consultation, or in the absence of complex
medical issues, patients may have preoperative NTproBNP
testing ordered by the anesthetist in the PAC. Due to COVID-19,
anesthesiology provides virtual assessments for most patients.
On the day of the surgery, the perioperative anesthesiologist
ensures that patients have had NTproBNP testing as appropriate.
If indicated, but not yet performed, NTproBNP is either added to
other recent blood work or drawn preoperatively. In patients with
an NTproBNP >200 ng/L, postoperative troponin levels and ECG
testing are ordered electronically. In the absence of surgical step-
down units at St. Paul’s, patients with NTproBNP >1500 ng/L are
monitored in the anesthesia-run surgical high acuity unit for at
least 24 h postoperatively. On the regular surgical wards, patients
with elevated preoperative NTproBNP remain on the anesthesia
perioperative list to facilitate monitoring of postoperative troponin
levels. The surgeon continues as the MRP and overnight calls are
managed by the surgical service. Patients with elevated troponin
levels are assessed on the surgical ward by the perioperative
anesthesiologist, and internal medicine is consulted for evaluation,
risk stratification, and follow-up care. To assist in patient management,
a GIM vascular medicine clinic provides three half-day clinics per
week to manage postoperative complications such as MINS with
in-person or virtual patient visits.
The Juravinski Hospital Model, Hamilton
Located in Hamilton, Ontario, and affiliated with the Population
Health Research Institute, the Juravinski Hospital was one of the
first centers to implement perioperative biomarker measurements
as part of routine perioperative management. With nine operating
rooms were used daily, this hospital performs over 6500 noncardiac
surgeries annually, of which nearly 70% are inpatient procedures and
26% are considered urgent. Initially developed as a cardiology-run
service with focus on preoperative evaluation and postoperative
cardiac events, this model of care evolved from consultants working
in isolation, to a dedicated perioperative service comprising GIM
and cardiology services, working closely with the anesthesiology
service. NTproBNP is typically ordered by the anesthesiology service
during the preoperative assessment and patients with NTproBNP
>100 ng/L are referred to this perioperative service. Pre-printed
order sets are used to ensure that postoperative monitoring is
ordered appropriately
Until recently, preoperative NTproBNP testing was not
available as an onsite test with timely results. The availability
of point-of-care (POC) NTproBNP testing allowed for rapid,
individualized patient assessment. Limitations of POC NTproBNP
testing include the need for a specific handheld device for each
provider or shared clinic, the cost per test being $15.00–22.00,
24
and integrating the results into the patient’s electronic medical
record (though some systems report seamless integration with
hospital computer systems).
25
Prior to integrating POC results
electronically, establishing accuracy with a laboratory based
NTproBNP and related quality control measures would be required.
At the very least, the NTproBNP result can be highlighted in
a dictated consultation note. Due to COVID-19, preoperative
assessments are often performed remotely and preoperative
NTproBNP may be less readily available. POC NTproBNP
immediately prior to the OR may be an option to help guide
the need for postoperative troponin monitoring.
The Juravinski perioperative inpatient service is staffed by a GIM
or cardiology attending, a nurse practitioner (NP), and a resident/
fellow. The service provides GIM consultative support including
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atrial fibrillation, heart failure, and MINS. Other cardiology concerns
are referred to the cardiology consult service. The surgeon remains
the MRP, and overnight concerns are directed to the surgical team
with infrequent involvement of the IM senior resident. Prior to
COVID-19, the preoperative clinic ran 5 days/week (now 3 half
days) and postoperative clinic started at 1 half day/week and now
runs 3 half days/week with demand to expand further.
A Tailored Approach to Preoperative BNP/
NTproBNP and Postoperative Troponin Screening
As discussed, implementing a perioperative biomarker screening
program follows the 2017 CCS guidelines. Determining the right
approach requires a multifaceted evaluation of current workplace
culture; key stakeholders; local interest and expertise; and
identification of short-, medium-, and long-term goals. A local
champion(s) who can drive the process is essential. To facilitate
the analysis of a center’s current approach and for strategies on
how to implement a perioperative biomarker screening program,
consider the following questions:
Assess Current Culture
• Aside from the surgeon, who else is providing perioperative
care?
• What risk stratification tools are currently being used? What
are the validity, availability, and cost of these tools?
• Who could order preoperative BNP/NTproBNP (i.e., surgeon,
anesthesia, or IM)?
• How could BNP/NTproBNP be ordered (i.e., add to surgeon’s
routine preoperative blood work on EMR, creation of PPO,
anesthetist to request for blood work in PAC, or POC testing
in surgeon’s office, PAC, or immediately prior to surgery)?
• Who would follow up on the BNP/NTproBNP result? Is there
an established referral pathway for abnormal values (i.e., are
timely perioperative medicine consults available)?
• How are patients at an increased risk of postoperative MACE
being identified and monitored?
• What capacity exists to see patients with postoperative
troponin elevation in a timely manner? If limited, what would
need to change to facilitate this important step? Is there a role
for a nonphysician (i.e., NP or Physician Assistant (PA)) to
help with staffing and workload?
• What follow-up options exist locally or virtually for patients
with postoperative complications such as MINS?
• What aspects of preoperative and postoperative care are
working well?
• Where is the room for improvement?
Identify Key Stakeholders, Including but Not Limited To
• Anesthesia
• Surgery
• Internal medicine
• Cardiology
• Geriatrics
• Primary care provider
• Laboratory medicine
• Nurses (surgical screening, PACU, surgical ward)
• Hospital administration
• Patient care office
• Quality improvement office
• Physician engagement groups (is funding available to help
facilitate an interdisciplinary team?)
Assess Level of Local Expertise and Interest
• Are the key stakeholders familiar with the CCS perioperative
guidelines?
• If not, what would be required to get all of the key stakeholders
familiar with and motivated to implement guideline-driven
care (i.e., grand rounds, guest speaker, CME event)?
• Who could serve as a “champion” from key disciplines to steer
a committee?
• Are there any obvious barriers (i.e., time constraints,
interpersonal issues, territorial services, knowledge deficits,
funding issues)?
• Securing physician engagement funding enhances meeting
attendance, helps physicians feel their time and their expertise
is valued, promotes team building, and enhances collegiality
across disciplines.
26
Determine a Starting Point and Consider Medium to
Long-Term Goals
• What is needed right now to improve patient safety and care?
If implementing a system hospital wide is daunting, consider a
select group of higher risk surgical patients as a starting point.
• Who is available to assist with this project right now? How
much bandwidth do they have? Are scheduling or funding
changes required to increase the likelihood of success? Is
dedicated training required?
• Start small and expand in time.
• Medium- to long-term goals: consider recruiting physicians
with interest or expertise in perioperative care and/or
mentoring trainees with an interest in perioperative medicine.
How can patient outcomes and other metrics like LOS be
tracked? What opportunities exist to contribute to research in
perioperative medicine?
Consider Creating PPO
• Ideally an interdisciplinary group effort, get buy-in from key
stakeholders
• Standardizes patient care and provides clarification of who to
call and when
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Table 1. Establishing a Perioperative Biomarker Screening Program: Commonly Encountered Challenges and Proposed Solutions
Challenge Solutions
• Insufficient physicians interested/available to
staff a new service, pre-/postoperative clinic,
or to accommodate increased workload
• Remuneration insufficient to create a stand-
alone perioperative service
• Issues in arranging timely postoperative clinic
follow-up for patients with MINS (or other
medical complications).
• Recruit physicians and/or mentor trainees interested in perioperative care.
• Consider an integrative perioperative service (combination of anesthesia, IM, cardiology, geriatrics,
etc.).
• Automatic consults for patients meeting high-risk criteria to ensure that the service is financially
viable.
• Integration of a dedicated perioperative NP/PA to prevent overwhelming clinician resources or to
allow the physician to schedule concurrent pre-/postoperative clinics.
• NP/PA funding could come from the surgical or shared budgets.
• Inconsistent practice patterns within
disciplines.
• Knowledge deficits of CCS guideline
recommendations and/or literature on
perioperative risk and role of perioperative
biomarkers, evidence, and strategies for
intervention for patients with MINS.
• Educational rounds, journal club, CME events, virtual guest speakers.
• Create PPOs to standardize practice.
• Spending time, and/or arrange electives for trainees, at centers with established perioperative
services and biomarker screening programs.
• Provide updates in perioperative care for surgical/medical trainees.
• Attend the annual Perioperative Care Congress to keep up with advances in perioperative medicine,
ongoing and future research and trials.
• Patient responsibility—MRP • Determine a shared care model that works for surgical and medical teams.
• Establish consensus on appropriate transfer of care, including revision of existing interservice patient
transfers protocols to find a model that satisfies all clinicians and optimizes patient care.
• Patient responsibility—evening and weekend
coverage (staffing and remuneration)
• Agreement from surgical and medicinal services on routine and urgent care in the evening/on weekends.
• Consider a perioperative clinical associate (CA), typically fulfilled by senior residents/fellows; these
paid overnight and/or weekend shifts help to offload the admitting on-call team by managing
urgent overnight ward issues. Funding could come from surgical, medical, or mixed sources.
• A dedicated perioperative service may assume MRP status for select surgical patients.
• Concerns regarding increased LOS with IM
involvement
• Evidence supports a shorter LOS with shared care models.
19,20,23
• If concerns regarding LOS are a major obstacle, consider a pilot project to assess the impact on LOS.
• Timely and reliable biomarker testing (urgent/
emergency patients, transitioning care [and
lab orders] from outpatient to inpatient
setting).
• Anesthetists may be uncomfortable ordering
postoperative troponin testing as they are
unable to follow the result once the patient is
on the ward.
• The CCS guidelines recommend against any delay in urgent/emergent surgical cases to perform risk
assessment (including BNP/NTproBNP); consider adding BNP/NTproBNP level to preoperative blood
work already drawn, or POC testing, for guiding postoperative monitoring needs.
• PPOs help to ensure postoperative troponin testing is ordered appropriately. Once surgery is
completed, the anesthetist can highlight if there is an indication for troponin testing and complete,
or prompt the surgical team to complete, the PPO.
• Some hospital systems may allow for direct order entry of postoperative troponin.
• Cost and availability of biomarker testing. • There is value in a site-specific cost analysis for BNP/NTproBNP, troponin, and ECG, particularly
in contrast to other types of preoperative testing like stress testing or echocardiogram (no longer
routinely recommended by CCS guidelines but may still be in practice for some).
• For centers without onsite BNP/NTproBNP testing or without access to timely results, consider POC
testing.
• If BNP/NTproBNP testing is unavailable, consider routine postoperative ECG and troponin testing per
CCS guidelines.
5
• Patients and/or surgeons are uncomfortable
with higher risk estimates determined by
preoperative BNP/NTproBNP testing.
• The use of BNP/NTproBNP allows for more accurate risk estimates with one in four patients reclassified
to a more appropriate risk category of medical (not surgical) complications versus RCRI alone.
6
• Day surgery patients. • We do not yet have evidence to implement perioperative biomarker use in day surgery patients.
CCS, Canadian Cardiovascular Society; CME, continuous medical eduction; ECG, electrocardiogram; LOS, length of stay; MINS, myocardial injury after noncardiac surgery; MRP, most responsible
physician; NP, nurse practitionner; PA, physician assistant; PPO, preprinted order set; POC, point-of-care; RCRI, Revised Cardiac Risk Index
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Summary
The standard of care for adults undergoing inpatient, noncardiac
surgery now includes the use of preoperative BNP/NTproBNP to
provide an individualized perioperative risk assessment and routine
postoperative troponin monitoring to detect myocardial injury
for high-risk patients. Accurate risk prediction is important for
informed consent, consideration of alternative surgical strategies,
and planning for appropriate postoperative monitoring. Growing
evidence demonstrates increased morbidity and mortality of
patients who suffer from MINS, an entity that would be largely
undetected without biochemical monitoring.
2,11
Strategies for
pharmacotherapy intensification have been shown to improve
outcomes for patients with MINS.
15,16
Clinicians interested in developing a preoperative BNP/
NTproBNP and postoperative troponin screening program will
benefit from a site-specific strategy and assessment of clinical,
funding, and laboratory resources. This article highlights several
successful, yet unique, approaches to establishing sustainable
perioperative biomarker monitoring programs. Detailed solutions
to commonly encountered challenges have been highlighted
along with strong encouragement for the consideration of a
multidisciplinary, shared-care model to facilitate the implementation
of perioperative biomarker screening, to improve patient outcomes
and to increase clinician satisfaction.
19–21,24
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