MINS is one of the most consequential and underappreciated phenomena in modern perioperative medicine. It is defined as a rise in cardiac troponin, a protein released when heart muscle cells are damaged, above the 99th percentile of the normal reference range in the days following an operation that does not involve the heart itself. Crucially, most patients with MINS experience no chest pain, no shortness of breath, and no electrocardiographic changes, because the injury is often a diffuse supply-demand mismatch rather than a classic clot-blocking heart attack. The landmark VISION studies, which screened tens of thousands of surgical patients with high-sensitivity troponin assays, demonstrated that postoperative troponin elevation independently predicts 30-day mortality, even when the injury is asymptomatic. This is why the American Heart Association and the European Society of Cardiology have issued dedicated guidance urging clinicians to consider troponin surveillance in high-risk noncardiac surgery populations.

The new study, led by Yiwen Liu, Yongping Ma, and Yuxing Guo across institutions including Peking University School and Hospital of Stomatology, Peking University International Hospital, and Baoding Second Hospital, focused on a patient group that sits at the intersection of oncology, dentistry, and cardiology. The researchers analyzed 65 patients with cancer-related MRONJ who underwent surgical treatment between October 2024 and May 2025. Blood levels of high-sensitivity cardiac troponin I, one of the most sensitive biochemical detectors of heart muscle damage available, were measured before surgery and again within 72 hours afterward. MINS was diagnosed according to established international criteria, and the clinical characteristics of patients who developed the condition were systematically compared with those who did not.

The headline finding was stark in its simplicity: 7 of the 65 patients, or 10.8 percent, developed MINS. That figure may appear modest, but in a population already weakened by cancer and its therapies, it represents a meaningful signal. Postoperative myocardial injury is not a benign laboratory curiosity; it is a predictor of major adverse cardiac events and death, and identifying who is vulnerable before the scalpel touches tissue is one of the central goals of perioperative risk stratification. What makes this study particularly interesting is not just the incidence but the pattern of risk factors that emerged when the investigators compared the two groups.

Patients who developed MINS had a significantly lower body mass index than those who did not, a difference that reached statistical significance at P = 0.003. They also had a higher prevalence of preoperative myocardial injury, meaning their troponin levels were already elevated before the operation began, a finding significant at P = 0.005. In addition, the MINS group showed lower preoperative serum albumin levels, a marker of protein nutrition and overall nutritional reserve, and significantly more severe anemia, defined using World Health Organization hemoglobin cutoffs. Spearman correlation analysis quantified these relationships: MINS showed a moderate positive correlation with preoperative myocardial injury, with a correlation coefficient of 0.435, and a negative correlation with BMI, at minus 0.366. The correlations among BMI, serum albumin, and anemia severity themselves were also significant, painting a picture of interconnected vulnerability rather than isolated risk factors.

The physiological logic behind these associations is compelling. A patient with low BMI and hypoalbuminemia is often malnourished or cachectic, with depleted cardiac reserve, reduced antioxidant defenses, and impaired capacity to tolerate the inflammatory surge that accompanies any surgical intervention. Anemia compounds the problem by reducing the oxygen-carrying capacity of the blood, forcing the heart to beat faster and harder to deliver the same amount of oxygen to tissues, including the myocardium itself. Under general anesthesia, blood pressure fluctuates, oxygen demand shifts, and the balance between myocardial oxygen supply and demand becomes precarious. In a heart already operating near its limits, that balance can tip, producing the subclinical myocyte damage that registers as a troponin rise. Preoperative myocardial injury, meanwhile, marks a myocardium that is already stressed, making it the strongest correlated factor in the study.

The context of the operation matters as much as the patient. MRONJ surgery is performed on the jaw, far from the heart, yet it involves infection, inflammation, and often prolonged procedures in patients taking multiple medications. Cancer itself is now recognized as an independent risk factor for perioperative arterial ischemic events, and the emerging discipline of cardio-oncology, codified in the 2022 European Society of Cardiology guidelines, emphasizes that cancer therapies, shared risk factors such as diabetes and smoking, and the systemic inflammatory state of malignancy all conspire to elevate cardiovascular risk. Patients with MRONJ are typically receiving or have received long courses of antiresorptive therapy, and many have breast cancer, prostate cancer, or multiple myeloma, diseases whose treatments can themselves affect the heart. The study’s authors positioned their work within this cardio-oncology framework, noting that non-cancer mortality is a major contributor to overall mortality among people diagnosed with cancer.

What distinguishes this investigation is its emphasis on nutrition as a modifiable axis of perioperative risk. Serum albumin has long served as a workhorse biomarker in surgical outcome prediction, appearing in composite indices such as the prognostic nutritional index, and low values consistently correlate with worse postoperative outcomes across surgical specialties. By demonstrating that BMI, albumin, and anemia cluster together and jointly associate with MINS, the study suggests that nutritional assessment, a step often relegated to a brief checklist item, could become a genuine gatekeeping tool before jaw surgery in cancer patients. If malnourished, anemic patients can be identified weeks before surgery, clinicians have a window to optimize hemoglobin through iron supplementation or transfusion where appropriate, improve protein intake, and thereby potentially shift the supply-demand equation in the patient’s favor before the operative stress arrives.

The authors are appropriately cautious about the strength of their conclusions. This was an exploratory, retrospective study with a small sample size, and only seven patients experienced the outcome, a number that limits the statistical power of multivariable modeling; the field’s own methodological conventions, such as the events-per-variable rule from logistic regression research, caution against overfitting models built on so few events. The study followed STROBE reporting guidelines and was approved by ethics committees at all three participating institutions, but the authors explicitly state that the observed associations require confirmation in larger, prospective studies before they can drive clinical practice. Retrospective designs also cannot exclude confounding by unmeasured variables, and the 72-hour troponin window, while consistent with standard definitions, captures only the early postoperative period.

Even with those caveats, the study adds a distinctive piece to the growing mosaic of perioperative cardiology. It suggests that a seemingly minor maxillofacial operation in a cancer patient is not cardiovascularly neutral, that the troponin assay can unmask silent heart injury in this population, and that the body’s nutritional state, measured through something as mundane as body weight, blood protein, and hemoglobin, may determine whether the heart weathers the surgical storm. For clinicians managing MRONJ, the practical takeaway is a call to widen the preoperative lens: assess nutrition, check hemoglobin, and consider baseline troponin testing so that the patients most likely to sustain silent myocardial injury can be flagged, monitored, and supported. For the broader field, the finding reinforces a theme that has been building across perioperative medicine for a decade, namely that the heart’s fate after surgery is written partly in the blood, the body composition, and the biology of the patient long before the first incision is made.

Subject of Research: Myocardial injury after noncardiac surgery in oncology patients treated surgically for medication-related osteonecrosis of the jaw

Article Title: Myocardial injury in oncology patients undergoing noncardiac surgery for MRONJ: risk factors and nutritional associations

Article References: Liu, Y., Zhu, T., Zhou, B., Wang, P., Yang, Z., Yang, M., An, N., Liu, X., Wang, W., Chen, X., Zhang, Y., Ma, Y., & Guo, Y. (2026). Myocardial injury in oncology patients undergoing noncardiac surgery for MRONJ: risk factors and nutritional associations. Supportive Care in Cancer, 34(10), Article 1022. https://doi.org/10.1007/s00520-026-11259-9

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11259-9

Keywords: MRONJ, myocardial injury after noncardiac surgery, MINS, high-sensitivity troponin, cancer, perioperative risk, nutrition, anemia, hypoalbuminemia, body mass index, cardio-oncology, jaw surgery