For the millions of adults undergoing noncardiac surgery each year, cardiac complications represent one of the most preventable sources of serious harm. A shift away from blanket preoperative testing toward precision risk stratification could meaningfully reduce both unnecessary procedures and missed diagnoses — making this guideline synthesis relevant well beyond the operating room.
This narrative review consolidates the 2024 American Heart Association/American College of Cardiology guidelines with emerging clinical evidence on perioperative myocardial ischemia and the increasingly recognized entity known as myocardial injury after noncardiac surgery (MINS). The updated framework favors a stepwise, individualized evaluation pathway: clinical risk indices (such as the Revised Cardiac Risk Index) are applied first, followed by functional capacity assessment, with selective use of biomarkers and imaging reserved for intermediate- and high-risk patients. High-sensitivity cardiac troponins and natriuretic peptides are now positioned as meaningful additions to risk prediction models, capable of detecting subclinical myocardial injury that correlates strongly with elevated postoperative mortality even in the absence of classic ischemic symptoms. Crucially, the evidence does not support routine preoperative stress testing or prophylactic coronary revascularization in otherwise stable surgical candidates.
This represents a meaningful consolidation of years of evidence challenging the reflexive cardiology clearance model. The VISION study and related large cohort data have established that MINS — troponin elevation without classic MI criteria — carries substantial 30-day mortality risk, yet remains widely underdetected. Guideline-directed medical therapy, including uninterrupted statin therapy and careful antiplatelet management around surgery, emerges as the central risk-mitigation tool rather than anatomical revascularization. The practical implication is that preoperative evaluation should function as a genuine risk-optimization exercise, not a gatekeeping ritual. Key limitations of the current evidence base include the predominantly observational nature of MINS outcome data and the ongoing uncertainty around optimal troponin surveillance protocols. For health-conscious adults, this review underscores that long-term cardiovascular management — particularly statin adherence — has direct relevance to surgical safety, not just chronic disease prevention.