Myocardial Injury After Noncardiac Surgery (MINS): From Biomarker to Management—A Narrative Review

Background Myocardial injury after noncardiac surgery (MINS) is defined as prognostically relevant myocardial ischemia occurring within 30 days of noncardiac surgery. Despite affecting 8%–20% of patients undergoing major noncardiac procedures, MINS remains substantially underdiagnosed because it is typically asymptomatic. The condition is independently associated with 30‐day mortality of approximately 10% and a threefold increase in major adverse cardiovascular events. Methods and Results This narrative review synthesizes evidence from landmark trials (PeriOperative ISchemic Evaluation [POISE], POISE‐2, MANAGE, and PREVENT‐MINS), the VISION cohort study, and contemporary guidelines. A structured literature search was performed (PubMed, Cochrane, January 2000–March 2026). MINS pathophysiology involves perioperative stress, inflammation, sympathetic surge, and supply‐demand mismatch, distinct from Type 1 myocardial infarction, with > 85% of events asymptomatic. Routine postoperative troponin monitoring is supported in high‐risk patients defined by clinical criteria (known cardiovascular disease, cardiovascular risk factors including age ≥ 65 years, or symptoms suggestive of CVD) per ESC 2022 (Class I), with RCRI ≥ 2 as a supplementary screening threshold. The POISE trial showed that metoprolol reduces nonfatal MI but increases mortality and stroke. POISE‐2 showed no benefit for perioperative aspirin, with increased major bleeding. The MANAGE trial demonstrated that dabigatran 110 mg twice daily reduces major vascular complications by 28% (HR 0.72) but had limitations including 46% drug discontinuation and early termination; guideline support is Class 2b. The PREVENT‐MINS trial showed that ivabradine does not reduce MINS incidence. Observational data support statin therapy, but randomized evidence remains insufficient, and no major guideline provides a specific Class I or IIa recommendation for statin initiation specifically for MINS; therefore, statin therapy should be considered on an individual basis rather than as a mandatory intervention. Glucose–insulin–potassium remains investigational. Conclusions MINS represents a paradigm shift from symptom‐based to biomarker‐based perioperative cardiovascular surveillance. Implementation science is urgently needed to translate existing evidence into routine clinical practice, with fewer than 20% of high‐risk patients currently receiving indicated monitoring.