Preoperative Anemia and Coronary Artery Disease as Predictors of Major Adverse Cardiac Events After Open Abdominal Aortic Surgery

TL;DR

Preoperative anemia is a strong predictor of major cardiac events after abdominal aortic surgery, especially in patients with coronary artery disease.

Contribution

This study identifies preoperative anemia as an independent risk factor for cardiac events in patients with CAD undergoing AAA repair.

Findings

Anemia was a strong independent predictor of MACE (OR 4.46) in a reduced model.

In the full model, anemia remained the strongest predictor (OR 4.53) while CAD showed a borderline association.

No significant interaction was found between anemia and CAD in modifying MACE risk.

Abstract

Background/Objectives: Coronary artery disease (CAD) is highly prevalent in patients undergoing vascular surgery and is a major determinant of postoperative morbidity and mortality. Preoperative anemia is a well-recognized risk factor for adverse outcomes, including major adverse cardiac events (MACEs), but its independent impact in patients with CAD undergoing abdominal aortic aneurysm (AAA) repair remains unclear. Methods: We conducted a retrospective cohort study of 410 consecutive patients undergoing open AAA repair at a tertiary vascular center between 2023 and 2025. Preoperative anemia was defined as hemoglobin < 130 g/L and significant CAD as ≥70% luminal narrowing for non-left main disease or ≥50% for left main disease. The primary outcome was MACE (cardiovascular death, myocardial infarction, or stroke) during hospitalization. Baseline covariates included age, sex, diabetes mellitus (DM), chronic kidney disease (CKD), congestive heart failure (CHF), peripheral artery disease (PAD), and other relevant comorbidities. Multivariable logistic regression models were used to evaluate associations of anemia, CAD, and their interaction with MACE. Additionally, a composite risk group was created to examine MACE rates across mutually exclusive subgroups. Results: Among 410 patients, 314 (76.6%) had CAD and 116 (28.3%) had preoperative anemia. Overall, 67 patients (16.3%) experienced MACE. In the reduced model including only anemia and CAD, anemia remained a strong independent predictor of a MACE (OR 4.46, 95% CI 2.57–7.72, p < 0.001), and CAD was also independently associated (OR 2.20, 95% CI 1.00–4.72, p = 0.044). In the full multivariable model adjusting for DM, CHF, CKD, PAD, and age, anemia was the strongest predictor (OR 4.53, 95% CI 2.49–8.26, p < 0.001), while CAD showed a borderline association (OR 2.07, 95% CI 0.94–4.57, p = 0.071). Interaction analysis indicated no statistically significant modification in risk by the combination of anemia and CAD. The composite risk group variable was omitted due to collinearity with its components. Conclusions: Preoperative anemia, particularly in patients with CAD, is a significant and independent predictor of major adverse cardiac events following open AAA repair. These findings support the importance of early identification and correction of anemia before surgery to improve perioperative cardiac outcomes in this high-risk population.