What question did this study set out to answer?

Consolidate existing evidence to evaluate the impact of frailty on mortality and postoperative complications in elderly patients undergoing cardiac surgery.

April 26, 2026BMC GeriatricsOpen Access

Frailty and postoperative complications in elderly patients undergoing cardiac surgery: a systematic review and meta-analysis

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Why the study?

Current evidence regarding the specific impact of frailty on cardiac surgery in elderly patients remained ambiguous.

Does frailty increase the risk of mortality and postoperative complications in elderly patients undergoing cardiac surgery?

Key Points

Consolidate existing evidence to evaluate the impact of frailty on mortality and postoperative complications in elderly patients undergoing cardiac surgery.
Systematic search conducted across PubMed, Web of Science, Cochrane, and Wanfang databases from inception through February 17, 2026 (registered in PROSPERO: CRD420251115942).
Included 25 studies (20 original studies and five database studies) examining older patients (predominantly aged ≥60 years) evaluated with tools including the Fried Frailty Phenotype and Johns Hopkins ACGs frailty indicator.
All-cause mortality was significantly higher in frail patients in original studies (RR 3.63; 95% CI, 2.78-4.72; I2 = 19%; P < 0.001) and database studies (RR 3.84; 95% CI, 3.63-4.06; I = 74%; P < 0.001).
Frail patients exhibited higher odds of postoperative stroke (OR 2.81; 95% CI: 2.08-3.81; I2 = 0%; P < 0.001), delirium (OR 2.08; 95% CI: 1.53-2.81; I2 = 40%; P < 0.001), and atrial fibrillation (OR 1.30; 95% CI: 1.03-1.65; I2 = 0%; P = 0.03).

Structured PICO

Does frailty increase the risk of mortality and postoperative complications in elderly patients undergoing cardiac surgery?

Population

25 studies (20 original, 5 database) pooling approximately 3,809,413 elderly patients (≥60 years) undergoing cardiac surgery, including both conventional open-heart procedures and transcatheter interventions.

Intervention

Frailty (assessed via various tools including Fried Frailty Phenotype, Johns Hopkins ACGs frailty indicator, Clinical Frailty Scale, etc.)

Comparator

Non-frail status

Outcome

All-cause mortality after cardiac surgery, atrial fibrillation (AF), delirium, and strokehard clinical

Frailty is a significant predictor of mortality, stroke, delirium, and other postoperative complications in elderly patients undergoing cardiac surgery, supporting the routine use of preoperative frailty assessments.

Limitations

Categorization of pre-frailty into a dichotomous state (frail vs. non-frail) may introduce potential heterogeneity.
Diversity of cardiac surgeries (minimally invasive surgeries vs complex open-heart surgeries) was a source of heterogeneity.
Database studies aggregated data from numerous hospitals over extended periods, with variations in institutional discharge protocols and regional healthcare policies.

Implication

Supports preoperative frailty assessment for elderly cardiac surgery patients; leaves open best strategies to mitigate risk.

Abstract

Frailty prevalence is high in elderly, especially those experiencing surgical operation. Identifying high-risk individuals who planned to receive surgery becomes imperative. Current evidence from observational studies suggesting the specific impact of frailty on cardiac surgery remains ambiguous, the systematic review and meta-analysis aimed to consolidate existing data to evaluate the impact of frailty on outcomes in elderly patients undergoing cardiac surgery. Searches were conducted in PubMed, Web of Science, Cochrane, and Wanfang database from inception to May 31, 2025, and the review was subsequently updated to February 17, 2026. The primary outcomes were all-cause mortality after cardiac surgery, atrial fibrillation (AF), delirium, and stroke. Secondary outcomes included other related complications including acute kidney injury (AKI), infection, pulmonary complications, bleeding, rehospitalization, nonhome discharge, length of intensive care unit (ICU) stay, length of hospital stay (LOS). Twenty-five studies were incorporated into the meta-analyses, involving 20 original studies and five database studies. The results showed that mortality among frail elderly patients undergoing cardiac surgeries was higher than non-frail counterparts both in original studies [risk ratio (RR) 3.63; 95% confidence interval (CI), 2.78-4.72; I2= 19%; P < 0.001] and database studies (RR 3.84; 95% CI, 3.63-4.06; I = 74%; P < 0.001). The risks of AF, delirium, stroke were higher in frail elderly patients: AF (OR 1.30; 95% CI: 1.03 - 1.65; I2 = 0%; P = 0.03), delirium (OR 2.08; 95% CI: 1.53 - 2.81; I2 = 40%; P < 0.001), stroke (OR 2.81; 95% CI: 2.08 - 3.81; I2 = 0%; P < 0.001). Frailty was significantly associated with increased risks of other postoperative complications in older patients after cardiac surgeries. Subgroup analyses indicated that database studies performed comparably to original studies in predicting postoperative complications, yet demonstrated significant heterogeneity in reporting outcomes. Our study underscores the pivotal impact of frailty on mortality, AF, delirium, stroke and other complications in the elderly patients undergoing cardiac surgeries. The results advocate for the incorporation of frailty assessments into the preoperative evaluation process. Registered in the International Prospective Register of Systematic Reviews (CRD420251115942).