Preoperative heart rate variability as a predictor of perioperative outcomes: a systematic review without meta-analysis

Heart rate variability (HRV) is a predictor of mortality and morbidity after non-lethal cardiac ischemia, but the relation between preoperatively measured HRV and intra- and postoperative complications is sparsely studied and most recently reviewed in 2007. We, therefore, reviewed the literature regarding HRV as a predictor for intra- and postoperative complications and outcomes. We carried out a systematic review without meta-analysis. A PICO model was set up, and we searched PubMed, EMBASE, and CENTRAL. The screening was done by one author, but all authors performed detailed review of the included studies. We present data from studies on intraoperative and postoperative complications, which were too heterogeneous to warrant formal meta-analysis, and we provide a pragmatic review of HRV indices to facilitate understanding our findings. The review was registered in PROSPERO (CRD42021230641). We screened 2337 records for eligibility. 131 records went on to full-text assessment, 63 were included. In frequency analysis of HRV, low frequency to high frequency ratio could be a predictor for intraoperative hypotension in spinal anesthesia and lower total power could possibly predict intraoperative hypotension under general anesthesia. Detrended fluctuation analysis of HRV is a promising candidate for predicting postoperative atrial fibrillation. This updated review of the relation between preoperative HRV and surgical outcome suggests a clinically relevant role of HRV but calls for high quality studies due to methodological heterogeneity in the current literature. Areas for future research are suggested.