Perioperative cardiovascular assessment for noncardiac surgery in elderly patients
Article information
Population aging refers to the increase in the proportion of elderly individuals in a population resulting from longer life expectancy and declining fertility and tends to characterize upper-middle and high-income countries, such as Organization for Economic Cooperation and Development (OECD) member countries. Statistics Korea reported that 18.4% of the total population was elderly (aged > 65 years) in 2023 [1]. If this trend continues, the elderly population will constitute over 20% of the population and Korea will become a super-aged society by 2025. The number of surgeries performed on elderly individuals continues to rise as the population ages. As the elderly population has age-related organ reserve decline and various medical comorbidities, surgery can provide a conclusive approach to treating several diseases related to aging. Although symptom relief and life extension are undeniable benefits of surgery, the risk of postoperative complications is more remarkable for the elderly than for the young [2].
Over 300 million people undergo major surgery annually, 85% of which undergo noncardiac surgery (NCS) [3]. Elderly patients are more vulnerable to perioperative adverse cardiac events (PACEs) and major adverse cardiac events, such as myocardial infarction or injury, cardiac arrest, or congestive heart failure, are firmly associated with perioperative death [4]. Adverse cardiac events can also result in significant complications, prolonged hospital stays, and increased medical costs [5]. In a national cohort of the United States, cardiovascular risk factors (e.g., hypertension, dyslipidemia, diabetes mellitus, obesity, and chronic kidney disease) and atherosclerotic cardiovascular disease (CVD), including coronary artery disease, peripheral artery disease, and prior stroke, increased over time among surgical patients undergoing major NCS [6]. However, the incidence of perioperative major adverse cardiovascular and cerebrovascular events declined from 3.1% to 2.6% in the same national cohort database [7]. These results suggest that the surgical population is getting older and sicker over time and that advancements in cardiovascular medicine, surgical techniques, and anesthetic management during the perioperative period are related to the decline in fatal cardiac events and mortality.
The current issue of the Korean Journal of Anesthesiology includes a nationwide multicenter retrospective cohort study conducted by Choi et al. [8] that uses Common Data Model data from seven tertiary hospitals and demonstrates an association between PACEs, defined as a composite of heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, myocardial infarction, coronary revascularization, or stroke within 30 days of surgery, and mortality after NCS. This study showed that the overall incidence of PACEs was 2.88% and PACEs were associated with increased 1-year and 3-year mortality. After 1:4 propensity score matching, the mortality rate was higher in the PACE group at the 1-year (6.0% vs. 4.4%; hazard ratio [HR]: 1.33, 95% CI [1.10, 1.60], P = 0.005) and 3-year (8.6% vs. 7.3%; HR: 1.18, 95% CI [1.01, 1.38], P = 0.038) follow-ups. The subgroup analyses of patient demographics and comorbidity showed that statistically significant risks were present in the older age group, emergency surgery group, and high surgical risk group. The event-specific analysis also revealed that all PACEs except stroke (HR: 1.22, 95% CI [0.90, 1.64], P = 0.194) were substantially linked to a higher risk of mortality. PACEs include not only major adverse cardiac events but also arrhythmic attacks, which are common and have previously been considered minor events. Thus, PACEs may offer a more precise assessment of the overall risk of cardiac events after NCS and may be an acceptable composite outcome for future clinical research.
The incidence of adverse cardiovascular events after NCS is influenced by both the surgical risk and patient-related risk factors, such as advanced age, CVD, or other risk factors (e.g., smoking, hypertension, diabetes, dyslipidemia, family disposition), and other existing medical conditions. For elderly patients, frailty, a frequent and critical geriatric condition defined by age-related reductions in multiorgan system physiologic reserve and function, increases the risk of adverse outcomes after surgery. European guidelines on cardiovascular assessments for NCS have been revised to include the recommendation that all patients aged ≥ 65 should undergo a heart examination before undergoing intermediate- or high-risk NCS [9]. For patients with established CVD or risk factors for CVD (including aged ≥ 65 years) or those presenting symptoms or signs indicating CVD (newly detected cardiac murmur, chest pain, dyspnea, or peripheral edema), the European guidelines recommend that a preoperative 12-lead electrocardiogram be obtained and high-sensitivity cardiac troponin levels be measured before and at 24 h and 48 h after intermediate- or high-risk NCS. The guidelines also provide a comprehensive set of recommendations for patients to mitigate the risk of cardiovascular problems before and after surgery. Prior to surgery, the application of risk reduction strategies, including smoking cessation, as well as the management of conditions such as hypertension, dyslipidemia, and diabetes are recommended. To minimize perioperative morbidity and mortality, conducting an individualized preoperative assessment and implementing general risk-reduction strategies are essential.
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Conflicts of Interest
No potential conflict of interest relevant to this article was reported.