Approximately 200 million noncardiac surgical procedures are performed every year, whereas nearly 20% of patients over the age of 45 years develop myocardial injury after noncardiac surgery (MINS). More importantly, the incidence of MINS is even higher in vascular surgery, as it is observed in over 40% of patients having open abdominal aortic surgery.¹

MINS is a serious complication associated with increased 30‑day mortality after noncardiac surgery. Several studies have thus been conducted to identify different strategies to improve preoperative risk stratification. In this context, cardiovascular biomarkers play a crucial role, specifically high‑sensitivity troponin T (TnT), brain natriuretic peptides, and, more recently, copeptin.^2-4 As was to be expected, preoperative elevated TnT concentrations were significantly associated with postoperative cardiovascular events and mortality.² In a large retrospective cohort study including over 7000 patients undergoing noncardiac surgery, Zhu et al² showed that the hazard ratio for 30‑day mortality in patients with a preoperative TnT concentration exceeding 14 ng/l was 3.9 (95% CI, 3.2–4.75; P <⁠0.001). In another large prospective cohort study including over 10 000 patients, Duceppe et al³ demonstrated that preoperative N‑terminal pro–B‑type natriuretic peptide natriuretic peptide (NT‑proBNP) concentrations are strongly associated with postoperative MINS and major cardiovascular complications. In fact, even a small preoperative NT‑proBNP elevation of more than 100 pg/ml was associated with an increased risk for MINS. Copeptin, a relatively novel biomarker, which has not been clinically well established yet, was studied as a predictor for postoperative cardiovascular complications.⁴ It was shown that elevated preoperative concentrations of copeptin were associated with a shorter cardio- and cerebrovascular event‑free survival.⁴

A considerable advantage of biomarkers is that they provide objective assessment of patients, without a risk of an observer bias. Although biomarkers are clinically established and simple to measure, the information regarding the underlying cause for their elevation in individual patients is highly limited. For example, elevated TnT or NT‑proBNP concentration in patients without any history of cardiovascular diseases is not easy to interpret and is most likely a result of multifactorial conditions, such as renal insufficiency.

Transthoracic echocardiography is a relatively simple and cost‑effective examination providing clinicians with detailed information in a few important areas. First, it helps with risk stratification, as it characterizes detailed baseline cardiac function including left ventricular ejection fraction (LVEF), valvular heart disease, or presence of heart failure. Second, it facilitates detection of cardiac conditions and aids in identification of undiagnosed diseases, pulmonary hypertension, or valvular heart diseases. Finally, it guides management, as the results can be gathered within minutes to optimize perioperative treatment.

Although preoperative echocardiography rapidly provides clinically important information, routine transthoracic echocardiography before noncardiac surgery, specifically in asymptomatic patients, is still not recommended in guidelines for preoperative risk stratification.⁵ Kim et al⁶ evaluated the predictive value of preoperative LV global longitudinal strain (LVGLS) for MINS and mortality in over 870 patients undergoing noncardiac surgery. They showed that an impaired LVGLS (below 16.6%), defined based on a receiver operating characteristic analysis, was significantly predictive for MINS.⁶ More interestingly, there was no significant difference in LVEF between impaired and nonimpaired LVGLS.⁶ Thus, LVGLS might be superior to assess perioperative myocardial function as compared with LVEF alone.

In this issue of Polish Archives of Internal Medicine, a retrospective cohort study by Studzińska et al⁷ evaluated the prognostic value of preoperative echocardiography on postoperative occurrence of MINS. Preoperative echocardiography images from 336 patients undergoing open aortic surgery because of infrarenal abdominal aortic aneurysm and / or peripheral arterial and aortic diseases were included.⁷ This study showed that regional wall abnormalities and LV septum hypertrophy, detected on preoperative echocardiography, were significantly associated with the occurrence of MINS.⁷ In fact, in 30% of patients, who had MINS, preoperative wall motion abnormalities were detected. In patients without MINS, the incidence of wall motion abnormalities was 15%.⁷ Interestingly, the authors also showed that preoperative LVEF was not associated with MINS.⁷ The result of this study clearly highlights the advantage of preoperative echocardiography, specifically in patients in whom major vascular surgery is planned, where great intraoperative stress on myocardium is expected. It seems likely that preoperative compensated wall abnormalities might decompensate during high intraoperative stress, which finally can lead to perioperative myocardial ischemia. Preoperative echocardiography might thus help to explain the higher incidence of MINS in vascular surgery patients.

When we take a glimpse into the near future, the next step would be to combine the results of the study by Studzińska et al⁷ with artificial intelligence (AI). AI will help to analyze echocardiographic images to identify abnormalities, standardize measurements, combine images with clinical data to provide a comprehensive individual risk profile. AI and echocardiography will enhance diagnostic accuracy and improve risk stratification to improve outcomes. AI might identify patients at a high risk for intraoperative myocardial ischemia and will help to guide treatment for these high‑risk patients. While these advancements present numerous benefits, the need for robust datasets and the importance of human oversight remain important considerations for the integration of AI into clinical practice. For this reason, data from preoperative echocardiography are of great importance for these technologies and should thus be encouraged.