Predictors of Perioperative Major Adverse Cardiovascular Events After Bariatric Surgery

Perioperative major adverse cardiac and cerebrovascular events after metabolic and bariatric surgery are uncommon but clinically important, particularly as the profile of patients undergoing surgery evolves in the era of expanded glucagon-like peptide-1 receptor agonist use. We analyzed adults undergoing primary laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry from 2019 through 2024 to determine the contemporary incidence of 30-day major adverse cardiac and cerebrovascular events and identify independent predictors of risk. Among 1,095,255 patients, 1,368 experienced a 30-day major adverse cardiac or cerebrovascular event, corresponding to an incidence of 0.12%. Events were more frequent after Roux-en-Y gastric bypass than sleeve gastrectomy. In multivariable analysis, the strongest independent predictors included dialysis dependence, prior myocardial infarction, prior pulmonary embolism, male sex, insulin-dependent diabetes, and greater antihypertensive medication burden. Each additional antihypertensive medication was associated with higher odds of perioperative events, supporting treatment intensity as a marker of cardiometabolic disease severity. In a subset with available heart failure data, heart failure was also independently associated with increased risk. These findings suggest that perioperative cardiovascular risk after metabolic and bariatric surgery is driven less by the presence of common comorbidities alone and more by markers of advanced systemic disease severity. Contemporary preoperative evaluation should prioritize patients with end-organ disease, insulin dependence, resistant hypertension, and established cardiovascular disease to guide optimization and individualized perioperative risk assessment.