Association of cardiovascular-kidney-metabolic syndrome with postoperative major adverse cardiovascular and cerebrovascular events after non-cardiac surgery

Background The Cardiovascular-Kidney-Metabolic (CKM) syndrome is highly prevalent among Chinese adults (over 80%), yet its specific association with postoperative outcomes in patients undergoing non-cardiac surgery has not been fully elucidated. This study aimed to evaluate the association between CKM stages and the risk of 30-day major adverse cardiac and cerebrovascular events (MACCE) after non-cardiac surgery, and to identify the specific stage at which risk increases significantly. Methods This single-center retrospective cohort study was conducted at the Second Affiliated Hospital of Army Medical University in Chongqing, China, including 178,232 adult patients aged 18 to 79 years who underwent non-cardiac surgery between July 1, 2016, and June 30, 2025. CKM Stages 0–4 were defined according to the 2023 American Heart Association scientific statement. The primary outcome was 30-day postoperative MACCE, a composite of all-cause mortality, non-fatal myocardial infarction, stroke, major arrhythmia, angina, pulmonary embolism, heart failure, or cardiac arrest. Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results Among the 178,232 patients (median age, 52 years; 55.3% female), 88.8% were at CKM Stage ≥ 1. The overall incidence of postoperative MACCE was 4.3%, which increased stepwise across CKM stages from 1.5% in Stage 0 to 15.9% in Stage 4. After full adjustment for demographics, surgical factors, and comorbidities, the aORs (95% CIs) for MACCE compared with Stage 0 were 1.11 (0.96–1.30, P > 0.05) for Stage 1, 1.41 (1.25–1.60, P < 0.001) for Stage 2, 2.19 (1.90–2.53, P < 0.001) for Stage 3, and 2.91 (2.55–3.34, P < 0.001) for Stage 4. Subgroup analysis showed that men had a higher MACCE risk than women at Stages 0–2, but no significant sex difference was observed at Stages 3–4 (interaction P = 0.68 for Stage 3; P = 0.23 for Stage 4). Sensitivity analyses yielded consistent results. Conclusions Higher CKM stages were independently associated with a stepwise increase in the risk of 30-day postoperative MACCE, with the risk becoming statistically significant at Stage 2. Whether this association should be used to guide perioperative management requires confirmation in prospective studies. While men exhibited a higher risk than women in Stages 0–2, the risk was similar between sexes in CKM Stages 3–4.