Frailty Assessment and Perioperative Major Adverse Cardiovascular Events After Non-Cardiac Surgery

  • Emaad Siddiqui
    Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
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  • Darcy Banco
    Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
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  • Jeffrey S. Berger
    Associate Professor, Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Avenue New York, NY 10016, USA
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  • Nathaniel R. Smilowitz
    Corresponding Author: Nathaniel Smilowitz, MD, MS, FACC, FSCAI, Assistant Professor of Medicine, The Leon H. Charney Division of Cardiology, NYU Langone Health, NYU School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY 10010, T: 212-263-5656 (Main)
    Associate Professor, Division of Cardiology, Department of Medicine, New York University School of Medicine, Veterans Affairs New York Harbor Health Care System, 423 East 23rd Street, 12W New York, NY 10010 USA
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Published:January 15, 2023DOI:


      • A validated risk score for frailty is associated with an increased risk for the composite of in-hospital mortality, acute myocardial infarction, or cardiac arrest after non-cardiac surgery.
      • The association between high frailty and surgical outcomes were observed across age groups, with greater odds of cardiac events observed in younger individuals.
      • High frailty scores are associated with an increased likelihood of non-home discharge after non-cardiac surgery.



      Frailty is an emerging risk factor for adverse outcomes. However, perioperative frailty assessments derived from electronic health records (EHR) have not been studied on a large scale. We aim to estimate the prevalence of frailty and the associated incidence of major adverse cardiovascular events (MACE) among adults hospitalized for non-cardiac surgery.


      Adults aged ≥45 years hospitalized for non-cardiac surgery between 2004-2014 were identified from the National Inpatient Sample. The validated Hospital Frailty Risk Score (HFRS) derived from International Classification of Diseases codes was used to classify patients as low (HFRS <5), medium (5-10), or high (>10) frailty risk. The primary outcome was MACE, defined as myocardial infarction, cardiac arrest, and in-hospital mortality. Multivariable logistic regression was used to estimate the adjusted odds of MACE stratified by age and HFRS.


      A total of 55,349,978 hospitalizations were identified, of which 81.0%, 14.4%, and 4.6% had low, medium, and high HFRS, respectively. Patients with higher HFRS had more cardiovascular risk factors and comorbidities. MACE occurred during 2.5% of surgical hospitalizations and was common among patients with high frailty scores (high HFRS: 9.1%, medium: 6.9%, low: 1.3%, p<0.001). Medium (adjusted odds ratio [aOR] 2.05, 95% CI 2.02 to 2.08) and high (aOR 2.75, 95% CI 2.70 to 2.79) HFRS were associated with greater odds of MACE versus low HFRS, with the greatest odds of MACE observed in younger individuals 45-64 years (interaction p-value <0.001).


      The HFRS may identify frail surgical inpatients at risk for adverse perioperative cardiovascular outcomes.



      EHR (electronic health record), MACE (major adverse cardiovascular events), AHRQ (Agency for Healthcare Research and Quality), NIS (National Inpatient Sample), ICD (International Classification of Disease), HFRS (hospital frailty risk score)
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