Patients undergoing noncardiac surgery have varying risk of cardiovascular complications. This study evaluated preoperative N-terminal pro–B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T to enhance cardiovascular events prediction for major noncardiac surgery.


This prospective cohort study included adult patients with cardiovascular disease or risk factors undergoing elective major noncardiac surgery at four hospitals in China. Blood samples were collected within 30 days before surgery for NT-proBNP and high-sensitivity troponin T (hs-TnT) measurements. The primary outcome was a composite of any cardiovascular events within 30 days after surgery. Logistic regression models were used to assess associations, and the predictive performance was evaluated primarily using area under the receiver operating characteristics curve (AUC) and fraction of new predictive information.


Between June 2019 and September 2021, a total of 2,833 patients were included, with 435 (15.4%) experiencing the primary outcome. In the logistic regression model that included clinical variables and both biomarkers, the odds ratio for the primary outcome was 1.68 (95% CI, 1.37 to 2.07) when comparing the 75th percentile to the 25th percentile of NT-proBNP distribution, and 1.91 (95% CI, 1.50 to 2.43) for hs-TnT. Each biomarker enhanced model discrimination beyond clinical predictors, with a change in AUC of 0.028 for NT-proBNP and 0.029 for high-sensitivity cardiac troponin T, and a fraction of new information of 0.164 and 0.149, respectively. The model combining both biomarkers demonstrated the best discrimination, with a change in AUC of 0.042 and a fraction of new information of 0.219.


Preoperative NT-proBNP and hs-TnT both improved the prediction for cardiovascular events after noncardiac surgery in addition to clinical evaluation, with their combination providing maximal predictive information.

Editor’s Perspective
What We Already Know about This Topic
  • Previous studies have shown that elevated preoperative plasma B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are associated with significantly increased adverse cardiovascular outcomes in noncardiac surgical patients, even after adjusting for known clinical risk factors.

  • It is well established that early elevation in postoperative troponin significantly and independently associates with increased adverse postoperative events in noncardiac surgical patients.

  • Fewer studies have assessed for a significant and independent association between elevated preoperative plasma high-sensitivity troponin T (hs-TnT) and increased adverse cardiovascular events after noncardiac surgery.

What This Article Tells Us That Is New
  • This cohort study used clinical data and plasma samples from 2,833 patients who underwent major noncardiac surgery to assess the ability of preoperative NT-proBNP and hs-TnT to predict postoperative adverse cardiovascular events.

  • Both elevations in preoperative NT-proBNP and hs-TnT predicted significant increase in the study’s composite adverse cardiovascular outcomes. The two biomarkers were similar in performance when adjusted for the Revised Cardiac Risk Index, and they both added to predicting adverse postoperative outcomes when considered together in logistic regression modeling.

  • This study indicates that increases in both preoperative NT-proBNP and hs-TnT significantly predict patients who experience adverse cardiovascular events after major noncardiac surgery.

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