Risk prediction models for delirium after adult cardiac surgery: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CHEN Min ¹ ,  YANG Amin ¹ , SUN Lu ²

1. Affiliated Jinling Hospital, Medical School of Nanjing University (General Hospital of Eastern Theater Command), Nanjing, 210002, P. R. China;
2. Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, P. R. China;

Corresponding author：

YANG Amin, Email: 504165799@qq.com

Keywords：

Cardiac surgery; postoperative delirium; risk prediction; model; system review/meta-analysis

DOI：

10.7507/1007-4848.202412032

Video：

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Objective To systematically evaluate the risk prediction models for postoperative delirium in adults with cardiac surgery. Methods The SinoMed, CNKI, Wanfang, VIP, PubMed, EMbase, Web of Science, and Cochrane Library databases were searched to collect studies on risk prediction models for postoperative delirium in cardiac surgery published up to January 29, 2025. Two researchers screened the literature according to inclusion and exclusion criteria, used the PROBAST bias tool to assess the quality of the literature, and conducted a meta-analysis of common predictors in the model using Stata 17.0 software. Results A total of 21 articles were included, establishing 45 models with 28733 patients. Age, cardiopulmonary bypass time, history of diabetes, history of cerebrovascular disease, and gender were the top five common predictors. The area under the curve (AUC) of the 45 models ranged from 0.6 to 0.926. Fourteen out of the 21 studies had good applicability, while the applicability of the remaining seven was unclear; 20 studies had a high risk of bias. Meta-analysis showed that the incidence of postoperative delirium in adults with cardiac surgery was 18.6% [95%CI (15.7%, 21.6%)], and age [OR=1.04 (1.04, 1.05), P<0.001], history of cerebrovascular disease [OR=1.76 (1.46, 2.06), P<0.001], gender [OR=1.73 (1.43, 2.03), P<0.001], minimum mental state examination score [OR=1.00 (0.82, 1.17), P<0.001], and length of ICU stay [OR=5.59 (4.29, 6.88), P<0.001] weer independent influencing factors of postoperative delirium after cardiac surgery. Conclusion The risk prediction models for postoperative delirium after cardiac surgery have good predictive performance, but there is a high overall risk of bias. In the future, large-sample, multicenter, high-quality prospective clinical studies should be conducted to construct the optimal risk prediction model for postoperative delirium in adults with cardiac surgery, aiming to identify and prevent the occurrence of postoperative delirium as early as possible.

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2.	Mali S, Haghaninejad H. Pulmonary complications following cardiac surgery. Arch Med Sci Atheroscler Dis, 2019, 4: e280-e285.
3.	Velazquez EJ, Lee KL, Jones RH, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med, 2016, 374(16): 1511-1520.
4.	Gupta KK, Ali S, Sanghera RS. Pharmacological options in atherosclerosis: A review of the existing evidence. Cardiol Ther, 2019, 8(1): 5-20.
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6.	Park J, Bonde PN. Machine learning in cardiac surgery: Predicting mortality and readmission. ASAIO J, 2022, 68(12): 1490-1500.
7.	Jiang JL, Zhang L, He LL, et al. Volatile versus total intravenous anesthesia on postoperative delirium in adult patients undergoing cardiac valve surgery: A randomized clinical trial. Anesth Analg, 2023, 136(1): 60-69.
8.	李瑛, 李贤煌, 胡燕, 等. 心脏外科术后患者发生谵妄危险因素的Meta分析. 解放军护理杂志, 2022, 39(6): 72-76.Li H, Li XH, Hu Y, et al. Risk factors of delirium occurrence in patients after cardiac surgery: A meta-analysis. Nurs J Chin PLA, 2022, 39(6): 72-76.
9.	Falsini G, Grotti S, Porto I, et al. Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: A prospective study (DELIRIUM CORDIS). Eur Heart J Acute Cardiovasc Care, 2018, 7(7): 661-670.
10.	Crocker E, Beggs T, Hassan A, et al. Long-term effects of postoperative delirium in patients undergoing cardiac operation: A systematic review. Ann Thorac Surg, 2016, 102(4): 1391-1399.
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13.	Krzych LJ, Wybraniec MT, Krupka-Matuszczyk I, et al. Complex assessment of the incidence and risk factors of delirium in a large cohort of cardiac surgery patients: A single-center 6-year experience. Biomed Res Int, 2013, 2013: 835850.
14.	Tse L, Schwarz SK, Bowering JB, et al. Incidence of and risk factors for delirium after cardiac surgery at a quaternary care center: A retrospective cohort study. J Cardiothorac Vasc Anesth, 2015, 29(6): 1472-1479.
15.	Mufti HN, Hirsch GM. Perioperative prediction of agitated (hyperactive) delirium after cardiac surgery in adults: The development of a practical scorecard. J Crit Care, 2017, 42: 192-199.
16.	Rao A, Shi SM, Afilalo J, et al. Physical performance and risk of postoperative delirium in older adults undergoing aortic valve replacement. Clin Interv Aging, 2020, 15: 1471-1479.
17.	Mufti HN, Hirsch GM, Abidi SR, et al. Exploiting machine learning algorithms and methods for the prediction of agitated delirium after cardiac surgery: Models development and validation study. JMIR Med Inform, 2019, 7(4): e14993.
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19.	He J, Ling Q, Chen Y. Construction and application of a model for predicting the risk of delirium in postoperative patients with type A aortic dissection. Front Surg, 2021, 8: 772675.
20.	Zhang S, Ji MH, Ding S, et al. Inclusion of interleukin-6 improved performance of postoperative delirium prediction for patients undergoing coronary artery bypass graft (POD-CABG): A derivation and validation study. J Cardiol, 2022, 79(5): 634-641.
21.	Li Q, Li J, Chen J, et al. A machine learning-based prediction model for postoperative delirium in cardiac valve surgery using electronic health records. BMC Cardiovasc Disord, 2024, 24(1): 56.
22.	Wang YP, Shen BB, Zhu CC, et al. Unveiling the nexus of postoperative fever and delirium in cardiac surgery: Identifying predictors for enhanced patient care. Front Cardiovasc Med, 2023, 10: 1237055.
23.	Yang T, Yang H, Liu Y, et al. Postoperative delirium prediction after cardiac surgery using machine learning models. Comput Biol Med, 2024, 169: 107818.
24.	Zhao X, Li J, Xie X, et al. Online interpretable dynamic prediction models for postoperative delirium after cardiac surgery under cardiopulmonary bypass developed based on machine learning algorithms: A retrospective cohort study. J Psychosom Res, 2024, 176: 111553.
25.	Liu C, Zhang L, Tang W, et al. A nomogram for predicting the risk of postoperative delirium in individuals undergoing cardiovascular surgery. Eur J Neurol, 2024, 31(12): e16483.
26.	洪亮, 孙加奎, 沈骁, 等. 心脏手术后谵妄的危险因素分析及预测模型构建. 临床麻醉学杂志, 2020, 36(12): 1195-1200.Hong L, Sun JK, Shen X, et al. Risk factors analysis and prediction model construction of postoperative delirium after cardiac surgery. J Clin Anesthesiol, 2020, 36(12): 1195-1200.
27.	刘海棠, 唐倩芸, 周森. 老年病人心脏术后谵妄风险列线图预测模型的建立及验证. 实用老年医学, 2021, 35(8): 840-844.Liu HT, Tang QY, Zhou S. Establishment and validation of nomogram model for prediction of delirium risk in elderly patients after cardiac surgery. Pract Geriatr, 2021, 35(8): 840-844.
28.	李雪苹, 王磊, 张淮, 等. Stanford A型主动脉夹层患者术后谵妄风险预测评分模型的构建与效果验证. 中华护理杂志, 2022, 57(8): 950-957.Li XP, Wang L, Zhang H, et al. Construction and evaluation of a risk prediction model of postoperative delirium in patients with Stanford type A aortic dissection. Chin J Nurs, 2022, 57(8): 950-957.
29.	徐萍. 老年心脏直视术后患者谵妄风险预测模型的构建及验证. 浙江中医药大学, 2022.Xu P. Construction and verification of prediction model of delirium risk in elderly patients after open heart surgery. Zhejiang University of Traditional Chinese Medicine, 2022.
30.	黄琦, 关美娇, 邹彬, 等. 机器学习模型预测心脏外科手术患者术后谵妄的有效性. 临床麻醉学杂志, 2023, 39(4): 363-369.Huang Q, Guan MJ, Zou B, et al. Effectiveness of machine learning models in predicting postoperative delirium in patients undergoing cardiac surgery. J Clin Anesthesiol, 2023, 39(4): 363-369.
31.	左都坤, 吴卓熙, 龙宗泓, 等. 基于机器学习算法构建心脏手术患者术后早期谵妄风险预测模型. 陆军军医大学学报, 2023, 45(8): 753-758.Zuo DK, Wu ZX, Long ZH, et al. Prediction model of early postoperative delirium risk based on machine learning algorithm in patients undergoing cardiac surgery. J Med Coll PLA, 2023, 45(8): 753-758.
32.	胡霄竹, 韩晴, 屈丽楠, 等. 冠状动脉旁路移植术术后谵妄的危险因素分析及预测模型的建立. 中国医药, 2024, 19(5): 679-683.Hu XZ, Han Q, Qu LN, et al. Analysis of risk factors for postoperative delirium after coronary artery bypass grafting and establishment of prediction model. China Med, 2024, 19(5): 679-683.
33.	Ten Broeke M, Koster S, Konings T, et al. Can we predict a delirium after cardiac surgery? A validation study of a delirium risk checklist. Eur J Cardiovasc Nurs, 2018, 17(3): 255-261.
34.	易进, 崔飞环, 梁玉兰, 等. 心脏外科术后谵妄的临床特点和危险因素分析. 心肺血管病杂志, 2024, 43(5): 469-473.Yi J, Cui FH, Liang YL, et al. Analysis of clinical characteristics and risk factors of postoperative delirium after cardiac surgery. J Cardiovasc Pulm Dis, 2024, 43(5): 469-473.
35.	Andrási TB, Talipov I, Dinges G, et al. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest. Eur J Cardiothorac Surg, 2022, 62(1): ezab570.
36.	沈立, 王恒, 付正晨, 等. 体外循环心脏术后谵妄. 中国体外循环杂志, 2024, 22(4): 345-348.Shen L, Wang H, Fu ZC, et al. Postoperative delirium after cardiopulmonary bypass. Chin J ECC, 2024, 22(4): 345-348.
37.	Baek W, Kim YM, Lee H. Risk factors of postoperative delirium in older adult spine surgery patients: A meta-analysis. AORN J, 2020, 112(6): 650-661.
38.	王东雄, 袁昕. 心脏外科术后谵妄的术前危险因素研究进展. 心血管病学进展, 2022, 43(8): 698-701.Wang DX, Yuan X. Preoperative risk factors of postoperative delirium in cardiac surgery. Adv Cardiovasc Dis, 2022, 43(8): 698-701.
39.	Wansrisuthon W, Ratta-Apha W, Thongchot L, et al. Accuracy of diagnosis and international classification of diseases; tenth revision coding for alcohol dependence, alcohol withdrawal, and alcohol-withdrawal delirium among inpatients at a university hospital. J Addict Med, 2017, 11(3): 241-242.
40.	Suzuki S, Brown CM, Dela Cruz CD, et al. Timing of estrogen therapy after ovariectomy dictates the efficacy of its neuroprotective and antiinflammatory actions. Proc Natl Acad Sci U S A, 2007, 104(14): 6013-6018.
41.	Oldham MA, Hawkins KA, Yuh DD, et al. Cognitive and functional status predictors of delirium and delirium severity after coronary artery bypass graft surgery: An interim analysis of the neuropsychiatric outcomes after heart surgery study. Int Psychogeriatr, 2015, 27(12): 1929-1938.
42.	王宇, 张诚, 吴庆琛. 心脏外科手术患者术后谵妄的发生率及其可干预危险因素: 一项基于倾向性评分匹配的前瞻性观察研究. 解放军医学杂志, 2024, 49(10): 1110-1116.Wang Y, Zhang C, Wu QC. Incidence and modifiable risk factors of postoperative delirium in patients undergoing cardiac surgery: A prospective observational study based on propensity score matching. Med J Chin PLA, 2024, 49(10): 1110-1116.
43.	黎芮彤, 岳玉川, 谷续洁, 等. 儿童难治性肺炎支原体肺炎风险预测模型的系统评价. 中国全科医学, 2025, 28(9): 1105-1114.Li RT, Yue YC, Gu XJ, et al. Risk prediction models for refractory mycoplasma pneumoniae pneumonia in children: A systematic review. Chin Gen Pract, 2025, 28(9): 1105-1114.
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1. Reamy BV, Williams PM, Kuckel DP. Prevention of cardiovascular disease. Prim Care, 2018, 45(1): 25-44.
2. Mali S, Haghaninejad H. Pulmonary complications following cardiac surgery. Arch Med Sci Atheroscler Dis, 2019, 4: e280-e285.
3. Velazquez EJ, Lee KL, Jones RH, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med, 2016, 374(16): 1511-1520.
4. Gupta KK, Ali S, Sanghera RS. Pharmacological options in atherosclerosis: A review of the existing evidence. Cardiol Ther, 2019, 8(1): 5-20.
5. 宋亚佩, 吴艳, 翟继卫. 心外科手术后医院感染特点及影响因素研究. 中国消毒学杂志, 2021, 38(11): 832-835.Song YP, Wu Y, Zhai JW. Clinical characteristics and influencing factors of nosocomial infections after cardiac surgery. Chin J Disinfect, 2021, 38(11): 832-835.
6. Park J, Bonde PN. Machine learning in cardiac surgery: Predicting mortality and readmission. ASAIO J, 2022, 68(12): 1490-1500.
7. Jiang JL, Zhang L, He LL, et al. Volatile versus total intravenous anesthesia on postoperative delirium in adult patients undergoing cardiac valve surgery: A randomized clinical trial. Anesth Analg, 2023, 136(1): 60-69.
8. 李瑛, 李贤煌, 胡燕, 等. 心脏外科术后患者发生谵妄危险因素的Meta分析. 解放军护理杂志, 2022, 39(6): 72-76.Li H, Li XH, Hu Y, et al. Risk factors of delirium occurrence in patients after cardiac surgery: A meta-analysis. Nurs J Chin PLA, 2022, 39(6): 72-76.
9. Falsini G, Grotti S, Porto I, et al. Long-term prognostic value of delirium in elderly patients with acute cardiac diseases admitted to two cardiac intensive care units: A prospective study (DELIRIUM CORDIS). Eur Heart J Acute Cardiovasc Care, 2018, 7(7): 661-670.
10. Crocker E, Beggs T, Hassan A, et al. Long-term effects of postoperative delirium in patients undergoing cardiac operation: A systematic review. Ann Thorac Surg, 2016, 102(4): 1391-1399.
11. 陈香萍, 张奕, 庄一渝, 等. PROBAST: 诊断或预后多因素预测模型研究偏倚风险的评估工具. 中国循证医学杂志, 2020, 20(6): 737-744.Chen XP, Zhang Y, Zhuang YY, et al. PROBAST: A tool for assessing risk of bias in the study of diagnostic or prognostic multi-factorial predictive models. Chin J Evid-Based Med, 2020, 20(6): 737-744.
12. Guenther U, Theuerkauf N, Frommann I, et al. Predisposing and precipitating factors of delirium after cardiac surgery: A prospective observational cohort study. Ann Surg, 2013, 257(6): 1160-1167.
13. Krzych LJ, Wybraniec MT, Krupka-Matuszczyk I, et al. Complex assessment of the incidence and risk factors of delirium in a large cohort of cardiac surgery patients: A single-center 6-year experience. Biomed Res Int, 2013, 2013: 835850.
14. Tse L, Schwarz SK, Bowering JB, et al. Incidence of and risk factors for delirium after cardiac surgery at a quaternary care center: A retrospective cohort study. J Cardiothorac Vasc Anesth, 2015, 29(6): 1472-1479.
15. Mufti HN, Hirsch GM. Perioperative prediction of agitated (hyperactive) delirium after cardiac surgery in adults: The development of a practical scorecard. J Crit Care, 2017, 42: 192-199.
16. Rao A, Shi SM, Afilalo J, et al. Physical performance and risk of postoperative delirium in older adults undergoing aortic valve replacement. Clin Interv Aging, 2020, 15: 1471-1479.
17. Mufti HN, Hirsch GM, Abidi SR, et al. Exploiting machine learning algorithms and methods for the prediction of agitated delirium after cardiac surgery: Models development and validation study. JMIR Med Inform, 2019, 7(4): e14993.
18. Wueest AS, Berres M, Bettex DA, et al. Independent external validation of a preoperative prediction model for delirium after cardiac surgery: A prospective observational cohort study. J Cardiothorac Vasc Anesth, 2023, 37(3): 415-422.
19. He J, Ling Q, Chen Y. Construction and application of a model for predicting the risk of delirium in postoperative patients with type A aortic dissection. Front Surg, 2021, 8: 772675.
20. Zhang S, Ji MH, Ding S, et al. Inclusion of interleukin-6 improved performance of postoperative delirium prediction for patients undergoing coronary artery bypass graft (POD-CABG): A derivation and validation study. J Cardiol, 2022, 79(5): 634-641.
21. Li Q, Li J, Chen J, et al. A machine learning-based prediction model for postoperative delirium in cardiac valve surgery using electronic health records. BMC Cardiovasc Disord, 2024, 24(1): 56.
22. Wang YP, Shen BB, Zhu CC, et al. Unveiling the nexus of postoperative fever and delirium in cardiac surgery: Identifying predictors for enhanced patient care. Front Cardiovasc Med, 2023, 10: 1237055.
23. Yang T, Yang H, Liu Y, et al. Postoperative delirium prediction after cardiac surgery using machine learning models. Comput Biol Med, 2024, 169: 107818.
24. Zhao X, Li J, Xie X, et al. Online interpretable dynamic prediction models for postoperative delirium after cardiac surgery under cardiopulmonary bypass developed based on machine learning algorithms: A retrospective cohort study. J Psychosom Res, 2024, 176: 111553.
25. Liu C, Zhang L, Tang W, et al. A nomogram for predicting the risk of postoperative delirium in individuals undergoing cardiovascular surgery. Eur J Neurol, 2024, 31(12): e16483.
26. 洪亮, 孙加奎, 沈骁, 等. 心脏手术后谵妄的危险因素分析及预测模型构建. 临床麻醉学杂志, 2020, 36(12): 1195-1200.Hong L, Sun JK, Shen X, et al. Risk factors analysis and prediction model construction of postoperative delirium after cardiac surgery. J Clin Anesthesiol, 2020, 36(12): 1195-1200.
27. 刘海棠, 唐倩芸, 周森. 老年病人心脏术后谵妄风险列线图预测模型的建立及验证. 实用老年医学, 2021, 35(8): 840-844.Liu HT, Tang QY, Zhou S. Establishment and validation of nomogram model for prediction of delirium risk in elderly patients after cardiac surgery. Pract Geriatr, 2021, 35(8): 840-844.
28. 李雪苹, 王磊, 张淮, 等. Stanford A型主动脉夹层患者术后谵妄风险预测评分模型的构建与效果验证. 中华护理杂志, 2022, 57(8): 950-957.Li XP, Wang L, Zhang H, et al. Construction and evaluation of a risk prediction model of postoperative delirium in patients with Stanford type A aortic dissection. Chin J Nurs, 2022, 57(8): 950-957.
29. 徐萍. 老年心脏直视术后患者谵妄风险预测模型的构建及验证. 浙江中医药大学, 2022.Xu P. Construction and verification of prediction model of delirium risk in elderly patients after open heart surgery. Zhejiang University of Traditional Chinese Medicine, 2022.
30. 黄琦, 关美娇, 邹彬, 等. 机器学习模型预测心脏外科手术患者术后谵妄的有效性. 临床麻醉学杂志, 2023, 39(4): 363-369.Huang Q, Guan MJ, Zou B, et al. Effectiveness of machine learning models in predicting postoperative delirium in patients undergoing cardiac surgery. J Clin Anesthesiol, 2023, 39(4): 363-369.
31. 左都坤, 吴卓熙, 龙宗泓, 等. 基于机器学习算法构建心脏手术患者术后早期谵妄风险预测模型. 陆军军医大学学报, 2023, 45(8): 753-758.Zuo DK, Wu ZX, Long ZH, et al. Prediction model of early postoperative delirium risk based on machine learning algorithm in patients undergoing cardiac surgery. J Med Coll PLA, 2023, 45(8): 753-758.
32. 胡霄竹, 韩晴, 屈丽楠, 等. 冠状动脉旁路移植术术后谵妄的危险因素分析及预测模型的建立. 中国医药, 2024, 19(5): 679-683.Hu XZ, Han Q, Qu LN, et al. Analysis of risk factors for postoperative delirium after coronary artery bypass grafting and establishment of prediction model. China Med, 2024, 19(5): 679-683.
33. Ten Broeke M, Koster S, Konings T, et al. Can we predict a delirium after cardiac surgery? A validation study of a delirium risk checklist. Eur J Cardiovasc Nurs, 2018, 17(3): 255-261.
34. 易进, 崔飞环, 梁玉兰, 等. 心脏外科术后谵妄的临床特点和危险因素分析. 心肺血管病杂志, 2024, 43(5): 469-473.Yi J, Cui FH, Liang YL, et al. Analysis of clinical characteristics and risk factors of postoperative delirium after cardiac surgery. J Cardiovasc Pulm Dis, 2024, 43(5): 469-473.
35. Andrási TB, Talipov I, Dinges G, et al. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest. Eur J Cardiothorac Surg, 2022, 62(1): ezab570.
36. 沈立, 王恒, 付正晨, 等. 体外循环心脏术后谵妄. 中国体外循环杂志, 2024, 22(4): 345-348.Shen L, Wang H, Fu ZC, et al. Postoperative delirium after cardiopulmonary bypass. Chin J ECC, 2024, 22(4): 345-348.
37. Baek W, Kim YM, Lee H. Risk factors of postoperative delirium in older adult spine surgery patients: A meta-analysis. AORN J, 2020, 112(6): 650-661.
38. 王东雄, 袁昕. 心脏外科术后谵妄的术前危险因素研究进展. 心血管病学进展, 2022, 43(8): 698-701.Wang DX, Yuan X. Preoperative risk factors of postoperative delirium in cardiac surgery. Adv Cardiovasc Dis, 2022, 43(8): 698-701.
39. Wansrisuthon W, Ratta-Apha W, Thongchot L, et al. Accuracy of diagnosis and international classification of diseases; tenth revision coding for alcohol dependence, alcohol withdrawal, and alcohol-withdrawal delirium among inpatients at a university hospital. J Addict Med, 2017, 11(3): 241-242.
40. Suzuki S, Brown CM, Dela Cruz CD, et al. Timing of estrogen therapy after ovariectomy dictates the efficacy of its neuroprotective and antiinflammatory actions. Proc Natl Acad Sci U S A, 2007, 104(14): 6013-6018.
41. Oldham MA, Hawkins KA, Yuh DD, et al. Cognitive and functional status predictors of delirium and delirium severity after coronary artery bypass graft surgery: An interim analysis of the neuropsychiatric outcomes after heart surgery study. Int Psychogeriatr, 2015, 27(12): 1929-1938.
42. 王宇, 张诚, 吴庆琛. 心脏外科手术患者术后谵妄的发生率及其可干预危险因素: 一项基于倾向性评分匹配的前瞻性观察研究. 解放军医学杂志, 2024, 49(10): 1110-1116.Wang Y, Zhang C, Wu QC. Incidence and modifiable risk factors of postoperative delirium in patients undergoing cardiac surgery: A prospective observational study based on propensity score matching. Med J Chin PLA, 2024, 49(10): 1110-1116.
43. 黎芮彤, 岳玉川, 谷续洁, 等. 儿童难治性肺炎支原体肺炎风险预测模型的系统评价. 中国全科医学, 2025, 28(9): 1105-1114.Li RT, Yue YC, Gu XJ, et al. Risk prediction models for refractory mycoplasma pneumoniae pneumonia in children: A systematic review. Chin Gen Pract, 2025, 28(9): 1105-1114.
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Latest ArticlesRisk prediction models for delirium after adult cardiac surgery: A systematic review and meta-analysis

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