January 10, 2026Anesthesia & Analgesia0 citations

Association of Preoperative Frailty and Postoperative Outcomes in Older Adults Undergoing Major Cardiac Procedures: A Systematic Review and Meta-Analysis

VTVetri ThangaveluUniversity of Toronto OBOjas BhatiaUniversity of Toronto AHAnushka HasijaMcMaster University

Key Result

Preoperative frailty in older adults undergoing major cardiac procedures was linked to significantly increased odds of 30-day mortality (OR 3.58) and renal complications (OR 2.72).

Key Points

This review aims to assess the prevalence of preoperative frailty in older adults undergoing major cardiac procedures and its association with postoperative outcomes.
Systematic review and meta-analysis of studies on older adults undergoing major cardiac procedures.
Search conducted in MEDLINE, Embase, and Cochrane databases for relevant English-language studies.
Included studies required validated frailty instruments and reported at least one postoperative outcome.
Noncardiac surgeries, minor procedures, and reviews were excluded.
Random-effects meta-analyses calculated odds ratios and standardized mean differences.
Overall prevalence of preoperative frailty was 16.8%.
Frailty significantly increased odds of postoperative delirium (OR, 4.11), infections (OR, 3.72), and renal complications (OR, 2.72).
Frailty correlated with an extended hospital stay (SMD, 0.69) and ICU stay (SMD, 0.72).
Increased odds of 30-day (OR, 3.58) and 1-year mortality (OR, 2.25) were associated with frailty.

Structured PICO

Does preoperative frailty increase the risk of adverse postoperative outcomes in older adults undergoing major cardiac procedures?

Population

11,667 older adults undergoing major cardiac procedures (CABG, aortic or mitral valve replacement or repair, TAVR, or combined procedures), mean age 71.9, 28% female, pooled from 19 studies.

Intervention

Preoperative frailty (assessed via validated instruments such as Fried Frailty Phenotype or Clinical Frailty Scale)

Comparator

Absence of preoperative frailty

Outcome

Postoperative outcomes including cardiac, respiratory, renal, infectious, stroke, and bleeding complications, postoperative delirium, hospital and intensive care unit (ICU) length of stay, nonhome discharge, hospital readmission, and both 30-day and 1-year mortalityhard clinical

Preoperative frailty affects nearly 1 in 5 older adults undergoing major cardiac procedures and is strongly associated with increased mortality, delirium, infections, and longer hospital stays.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

BACKGROUND: Frailty, characterized by reduced physiological resilience, is a pivotal risk factor in older adults undergoing major cardiac procedures. Although previous analyses have linked frailty to adverse surgical outcomes, knowledge gaps persist due to methodological inconsistency across frailty tools and limited synthesis of complications such as delirium, infection, and renal dysfunction. The objective of this systematic review and meta-analysis is to determine the prevalence of preoperative frailty in older adults undergoing major cardiac procedures, and assess its association with postoperative outcomes, including cardiac, respiratory, renal, infectious, stroke, and bleeding complications, postoperative delirium, hospital and intensive care unit (ICU) length of stay, nonhome discharge, hospital readmission, and both 30-day and 1-year mortality. METHODS: A prespecified protocol was registered with PROSPERO (CRD#42024574916), following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Embase, and Cochrane databases were searched for English-language studies of patients undergoing major cardiac procedures, including coronary artery bypass grafting (CABG), aortic or mitral valve replacement or repair, transcatheter aortic valve replacement (TAVR), or combined procedures. Validated frailty instruments (eg, Fried Frailty Phenotype, Clinical Frailty Scale) were required to determine preoperative frailty, along with reporting at least 1 postoperative outcome. Noncardiac surgeries, minor procedures, case reports, and reviews were excluded. Random-effects meta-analyses generated odds ratio (OR) or standardized mean difference (SMD) values with 95% confidence intervals (CI). RESULTS: Nineteen studies (n = 11,667; mean ± SD age 71.9 ± 8.1 years, 28% female) met inclusion criteria, spanning North America, Europe, Asia, and Oceania. The overall prevalence of preoperative frailty was 16.8%. Frailty was significantly associated with delirium (OR, 4.11; 95% confidence interval CI, 2.00–8.45; P <.001), infection (OR, 3.72; 95% CI, 2.27–6.12; P <.001), renal complications (OR, 2.72; 95% CI, 2.05–3.60; P <.001), and extended hospital (SMD, 0.69 ; 95% CI, 0.35–1.02; P <.001) and ICU (SMD, 0.72; 95% CI, 0.51–0.94; P <.001) stays. Frailty increased the odds of 30-day (OR, 3.58; 95% CI, 2.16–5.93; P <.001) and 1-year (OR, 2.25; 95% CI, 1.56–3.25; P <.001) mortality. CONCLUSIONS: Frailty affects nearly 1 in 5 older adults requiring major cardiac procedures. Frailty was significantly associated with adverse postoperative outcomes, including delirium, infections, renal complications, extended length of stay, and mortality. As frailty is potentially modifiable, targeted strategies—such as prehabilitation, nutritional optimization, and enhanced perioperative monitoring—may improve outcomes. Incorporating routine frailty screening into standard preoperative practice allows for earlier identification of high-risk patients, efficient resource allocation, and perioperative care planning.

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