Associations of accelerated biological aging with intraoperative hypotension in major surgery: a multicenter cohort study of 116,996 patients.

BACKGROUND: Intraoperative hypotension (IOH) is a prevalent hemodynamic complication associated with adverse postoperative outcomes. Identifying patients at high risk for IOH remains a challenge. Accelerated biological aging, reflecting cumulative physiological decline, may heighten susceptibility to hypotensive events by impairing cardiovascular homeostasis and autonomic regulation, making it a potent yet underutilized predictor in perioperative medicine. MATERIALS AND METHODS: This multicenter retrospective cohort study analyzed 116,996 adults undergoing major cardiac and non-cardiac surgery across three tertiary academic medical centers in Eastern China. Accelerated biological aging was measured using Phenotypic Age Acceleration (PhenoAgeAccel). Outcomes included incidence of IOH (Mean arterial pressure (MAP) < 60 mmHg), cumulative duration, and area under curve (AUC) below this threshold. AUC was calculated using the trapezoidal integration method to quantify the integrated area where MAP < 60 mmHg. Associations were assessed using generalized linear regression, adjusting for key confounders. RESULTS: Accelerated biological aging was significantly associated with elevated IOH risk (adjusted odds ratio per unit increase 1.04, 95% confidence intervals 1.02-1.06, p < 0.001), with risk increasing progressively across acceleration groups. Accelerated biological aging also correlated with prolonged IOH duration and increased AUC. Subgroup analyses suggested increased IOH susceptibility associated with accelerated biological aging across most subgroups except patients of 40-79 years and those underwent cardiac surgery. Several estimates had wide confidence intervals, indicating variability and uncertainty in the subgroup-specific effects. CONCLUSIONS: Accelerated biological aging was significantly associated with both increased risk and greater severity of intraoperative hypotension. These findings support the integration of biological aging metrics, such as PhenoAgeAccel, into preoperative risk assessment to optimize hemodynamic management in vulnerable surgical populations.