From Risk Stratification to Prevention of Myocardial Infarction: Integrating Imaging and Biomarkers in the Perioperative Setting

Perioperative myocardial infarction (MI) and myocardial injury after noncardiac surgery (MINS) remain major causes of postoperative morbidity and mortality, yet optimal perioperative cardiovascular risk stratification remains challenging. This narrative review examines how cardiovascular imaging and circulating biomarkers may be integrated to improve perioperative risk assessment and to support more individualized preventive strategies in patients undergoing noncardiac surgery. We reviewed major clinical guidelines, landmark perioperative cohort studies, and key investigations addressing coronary computed tomography angiography, coronary calcium burden, natriuretic peptides, and cardiac troponin in the perioperative setting. Available evidence suggests that imaging and biomarkers provide complementary information, with imaging primarily reflecting structural coronary disease burden and biomarkers reflecting myocardial stress, biological vulnerability, and perioperative injury. Such multimodal assessment may refine risk estimation beyond conventional clinical indices alone, particularly in selected intermediate-risk patients or those with uncertain functional capacity. However, important limitations remain. Current evidence is heterogeneous across study populations, testing strategies, and endpoints, and standardized pathways for integrating imaging and biomarkers into routine clinical decision-making are not yet established. In addition, cost-effectiveness, accessibility, and the extent to which improved risk discrimination translates into better perioperative outcomes remain uncertain. Overall, the integration of imaging and biomarkers offers a clinically relevant framework for moving from perioperative risk stratification toward prevention, but its practical implementation and outcome benefit require further prospective validation.