Cardiovascular journal of South Africa : official journal for Southern Africa Cardiac Society [and] South African Society of Cardiac Practitioners

Heart failure (HF) is a progressive, life-limiting condition that often leads to complex physical, emotional, and social needs. This study aimed to translate, culturally adapt, and validate the Turkish version of the Needs Assessment Tool: Progressive Disease-Heart Failure (NAT: PD-HF) to facilitate the timely identification of palliative care needs. A total of 98 patients with chronic HF, 91 caregivers, and 25 healthcare professionals participated in this single-centre validation study. The tool underwent forward-backward translation and pilot testing. Internal consistency was good (Cronbach's α = 0.812), and inter-rater and test-retest reliabilities were high (PABAK: 0.908-1.000). Most patients (84.7%) found the tool understandable, and 67.7% felt it enhanced care. Healthcare professionals from cardiology, intensive care, and palliative care rated it as clinically relevant and feasible. The Turkish NAT: PD-HF is a valid, reliable, and culturally appropriate tool for identifying the palliative care needs of patients with HF and their caregivers. This tool can be integrated into routine clinical practice to facilitate early identification of palliative care needs.

BACKGROUND:Coronary artery bypass grafting (CABG) in octogenarians remains a challenging but increasingly common procedure due to extended life expectancy and the growing burden of coronary artery disease in the elderly. This study aimed to evaluate sex-specific differences in perioperative characteristics and early outcomes in patients aged ≥80 years undergoing isolated CABG. METHODS:A total of 104 patients aged ≥80 years who underwent isolated CABG between 2017 and 2023 were retrospectively analysed. Patients were stratified by gender, and comparisons were made regarding preoperative comorbidities, intraoperative variables, and postoperative outcomes. The primary endpoint was in-hospital mortality. RESULTS:The mean age was 82.01 ± 2.04 years, with 64.4% male and 35.6% female patients. While body surface area was significantly higher in males (p < 0.001), EuroSCORE II was numerically higher in females (p = 0.18). Chronic obstructive pulmonary disease (COPD) and smoking were more prevalent in males (p = 0.039 and p < 0.001, respectively), whereas CABG x5 was more frequent in females (p = 0.043). ICU stay was significantly longer in males (p = 0.014).Overall mortality was low (3.8%) and not significantly different between genders. CONCLUSIONS:CABG in patients aged ≥80 years is associated with low early mortality and acceptable complication rates regardless of gender. Preoperative and intraoperative gender based differences may inform individualised perioperative management strategies in this growing patient population.

AIM:The aortic valve-sparing procedure is an elective option for patients with aortic aneurysms. The feasibility of the surgical method in treating acute type A aortic dissection is still controversial. We aimed to study the outcomes of the David V aortic valve-sparing root replacement procedure. METHODS:We studied 21 acute type A aortic dissection patients who received the David V re-implantation technique. Patients were followed up with annual postoperative echocardiograms. Follow-up was 100% complete, with a mean duration of 40 ± 26 months. RESULTS:In 15 (71%) patients, the David V re-implantation technique was performed together with hemiarch; in 6 (29%) patients, it was combined with total aortic arch replacement. Three (14%) patients died in the hospital. None of the patients developed aortic regurgitation (AI) greater than second-degree at discharge. One patient had 2+ AI during the follow-up period, and the others showed trace/no AI. CONCLUSION:The David V operation can be considered for younger patients with suitable anatomy for acute type A aortic dissection with favourable outcomes.

BACKGROUND:The prevalence of in-hospital acute coronary syndrome (ACS) has risen from 4% to 10% in Dakar cardiology departments over the past 15 years, while the management of patients with persistent ST-segment elevation myocardial infarction (STEMI) has improved thanks to the availability of catheterisation laboratories in multiple hospitals of the Senegalese capital, including our centre at Hôpital Principal Dakar (HPD). The aim of this study was to describe the clinical characteristics and short-term prognosis of patients with STEMI treated by percutaneous coronary intervention (PCI). METHODS:We conducted a single-centre descriptive study using prospective data collection from September 2020 to July 2022, including all patients with STEMI PCI-treatment at Hôpital Principal Dakar (HPD). RESULTS:Out of 1146 patients admitted to HPD's cardiology department, 156 (13.61%) had STEMI. Of whom 58.97% underwent PCI. The mean age of STEMI patients with PCI was 60 years, and 78.26% were male. 90.2% consulted within 12 hours, with an average time of 3.26 ± 3 hours. Almost all patients (98.9%) were in Killip class II. 84.8% had a qualifying ECG within the first 12 hours, with a mean of 3.95 ± 2.95 hours. Thrombolysis was performed in 10.86%. The radial approach was used in 89% of cases, and primary PCI was performed in 71.73% of patients. A drugeluting stent was exclusively implanted in 95.65% of cases. PCI was successful in 98.91% of patients. Three non-fatal periprocedural complications were noted. The in-hospital mortality rate was 4.34%. CONCLUSIONS:At HPD, the prognosis of STEMI has been improved by coronary angioplasty, albeit with delays in management still to be perfected.

INTRODUCTION:Urinary dopamine is associated with increased sodium excretion in experimental studies, and possibly contributes to blood pressure (BP) regulation and salts-ensitivity. Studies in humans are limited, and the potential association with potassium is unclear. We aimed to compare urinary dopamine/creatinine ratio and investigate the associations of urinary dopamine/creatinine ratio with BP, sodium, potassium, and sodium/potassium ratio (Na/K) in Black and White adults. METHODS:We included Black (n = 160) and White (n = 197) men and women aged 20-65 years. We recorded 24-hour BP, measured urinary dopamine and creatinine, and calculated their ratio. Urinary sodium and potassium were measured, and Na/K ratio calculated. RESULTS:Urinary dopamine/creatinine ratio was lower in the Black group (p = 0.030) as compared to the White group, while urinary dopamine metabolites were higher in the Black group (p ≤ 0.001) compared to the White group. In multiple regression analyses, the following significant associations were confirmed: urinary dopamine/creatinine ratio associated positively with sodium and potassium in both the Black and White groups (all ß ≥ 0.296; p < 0.001) and negatively with Na/K ratio (ß = -0.285; p < 0.001) only in the Black group. No associations were observed between urinary dopamine/creatinine ratio and BP. CONCLUSION:The lower levels of urinary dopamine in the Black group as compared to their White counterparts could be explained by the higher urinary dopamine metabolite levels in the Black group, due to a possible higher rate in the metabolism of urinary dopamine and low potassium levels observed in this group. The unique negative association between urinary dopamine and Na/K-_ratio only in the Black participants suggest that potassium may contribute significantly to the renal sodium-handling properties of renal dopamine in Black populations.

AIM:In this study our aim was to determine the effect of resting heart rate (HR) on the development of coronary collateral circulation (CCC) in patients with chronic total occlusion (CTO). METHODS:A total of 219 patients who had CTO on their coronary angiography were divided into two groups according to their collateral status. CCC was graded by Rentrop Classification. RESULTS:Patients with poor collaterals had significantly higher resting HR (79±13.9 vs 74.3±10.5, p=0.005) compared to patients with well collaterals. According to backward logistic regression analyses low HR (OR:0.974, p=0.033), high ejection fraction (OR:1.026, p=0.043) and the presence of CTO at the right coronary artery (OR7colon;3.201, p<0.001) were found to be significantly related with coronary collateral development. CONCLUSIONS:Increased heart rate was found to be a risk factor for poor collateral formation.

In this study, we explored hypertension (HT) management in urban Soweto, South Africa, involving 364 participants from primary healthcare clinics. At baseline, 40% of participants were prescribed one drug, and 53% were given two drugs. Thiazide diuretics and calcium channel blockers were most prescribed at baseline. Blood pressure (BP) control at the first follow-up was achieved by 50% of those on single-drug therapy and 52% of those on two-drug therapy. Men showed higher rates of uncontrolled BP (60%) compared to women (42%). Significant factors influencing BP reduction included age, sex, waist circumference, and treatment clinic. In this study, single and combination therapies yielded similar outcomes in BP control. The study suggests that HT treatment approaches varied between clinics, potentially due to comorbidities and continuity of care challenges. Further research is needed to identify best practices across different South African settings, considering drug availability and cost.

AIM:The electromechanical window (EMW) refers to the time interval between aortic valve closure and the end of the T-wave during the same cardiac cycle. Recent studies highlight the role of EMW in assessing the risk of ventricular arrhythmia. This study examines the predictive value of the EMW for ventricular arrhythmias in heart failure with reduced ejection fraction (HFrEF) patients with an implantable cardioverter defibrillator (ICD). MATERIALS AND METHODS:This single-centre study included 52 HFrEF patients with ICD. The patients were divided into two groups based on the presence or absence of anti-tachycardia pacing (ATP) or shock therapy during ICD interrogation: those without therapy (n = 28) and those with therapy (n = 24). EMW duration was measured by echocardiography. The groups were compared with sex and age-matched controls (n = 24). RESULTS:The groups were homogeneous in terms of age and sex. EMW was lower in the ICD therapy group compared to without therapy and control groups (-25.17 ± 31.5 vs. 0.61 ± 25.1 vs. 9.21 ± 21.1; respectively, p < 0.001), while ECG-QTc duration did not differ between groups (p = 0.053). An EMW value below -22.5 ms demonstrated 69% sensitivity and 79% specificity in predicting ventricular fibrillation (AUC: 0.766, 95% CI 0.598-0.935), 57% sensitivity and 83% specificity in predicting ATP/shock therapy (AUC: 0.722, 95% CI 0.577-0.866), 67% sensitivity and 82% specificity in predicting shock therapy (AUC: 0.770, 95% CI 0.620-0.921). CONCLUSION:EMW is an up-to-date parameter easily measured with echocardiography. Our study shows that negative extension of EMW is a valuable predictor of ventricular arrhythmias and ICD therapies.

OBJECTIVE:Acute kidney injury is a common complication of cardiac surgery, and factors such as advanced age, diabetes mellitus, and low left ventricular function are reported to be risk factors for the development of acute kidney injury after coronary artery bypass grafting (CABG). There are few studies in the literature reporting the relationship between preoperative low T3 syndrome and cardiac surgery-related acute kidney injury. In this study, ı aimed to evaluate the effect of preoperative free T3 levels on early postoperative kidney injury based on glomerular filtration rate and acute kidney injury development in isolated elective on-pump coronary artery bypass grafting patients. METHODS:The study was conducted in our hospital on patients who underwent isolated elective on-pump CABG surgery. Patients who underwent other open-heart surgery other than CABG, patients who had previously undergone open-heart surgery, patients who underwent off-pump CABG, patients with known preoperative renal failure, patients with known thyroid disease, and patients for whom the study data were not available were excluded. Finally, a total of 183 patients included in this study were examined and compared in two groups according to their preoperative fT3 levels. RESULTS:The mean preoperative fT3 value was 2.06 ± 0.74 in Group 1 and 2.93 ± 0.53 in Group 2 (p = 0,000). The preoperative glomerular filtration rate value was 86.36 ± 11.16 and 88.78 ± 15.79 in Group 1 and Group 2, respectively (p = 0.150). Preoperative Hgb, diabetes mellitus, and age data were similar in both groups (p = 0.487, p = 0.936, and p = 0.073, respectively). The mean glomerular filtration rate change ratio (postoperative/preoperative glomerular filtration rate) was 0.93 ± 0.13 and 1.05 ± 0.56 (p = 0.437) for Groups 1 and 2, respectively. CONCLUSION:As a conclusion, according to the results of this study, no association was found between preoperative low fT3 and the development of postoperative acute kidney injury in on-pump coronary artery bypass grafting patients. However, we believe that further prospective studies with larger patient numbers would be beneficial to investigate the relationship between specific thyroid hormone disorders and the development of acute kidney injury after coronary artery bypass grafting.

BACKGROUND:Atrial fibrillation (AF) is a complex disease with irregular ventricular response and tachycardia as a result of irregular and rapid contraction of the atria, with poor cardiovascular outcomes unless treated. Beta-blockers are commonly used agents in the treatment of AF. The effects of beta-blockers on bleeding continue to be evaluated. AIM:Bleeding is a common complication in AF. In current cases, the evaluation of bleeding contributes to the follow-up of the disease. Our study aims to evaluate the effect of beta-blockers on bleeding in patients with AF. METHOD:The study was conducted retrospectively, and a total of 4004 patients hospitalised in a cardiology outpatient clinic were included. The patients were divided into two groups: those using metoprolol (n = 2481) and those using bisoprolol (n = 1523). Bleeding rates were evaluated. RESULTS:Bleeding events in the entire group were as follows; gastrointestinal bleeding in 164 patients (35.65%), epistaxis in 109 patients (23.69%), eye bleeding in 47 patients (10.21%), genitourinary bleeding in 39 patients (58.47%), oral bleeding in 35 patients (7.60%), subcutaneous bleeding in 28 patients (6.08%), intracranial bleeding in 19 patients (4.13%), traumatic bleeding in 16 patients (3.47%), and haemoptysis in 3 patients (0.65%). Both Bleeding Academic Research Consortium (BARC) type ≥ 2 and BARC ≥ 3 bleeding events were significantly higher in the bisoprolol group (p < 0.001). CONCLUSION:According to this study, the risk of bleeding in AF patients using metoprolol was found to be lower than in patients using bisoprolol. Accordingly, using metoprolol in AF patients seems safer.

OBJECTIVE:Recent cardiovascular outcome trials have shown that sodium-glucose co-transporter 2 (SGLT2) inhibitors reduce cardiovascular events, but results regarding their effects on subclinical atherosclerosis are conflicting. In this study, we aimed to investigate the effect of dapagliflozin, a selective SGLT2 inhibitor, on subclinical atherosclerosis by monitoring pulse wave velocity (PWV) and carotid intima-media thickness (cIMT) in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS:Forty-eight patients with T2DM and on dapagliflozin treatment were included in the study. Demographic variables, anthropometric indices and laboratory parameters were obtained from the patient files. Baseline and 6th-month PWV and cIMT values were obtained. The percentage changes from baseline in all continuous variables with six months of dapagliflozin were calculated. RESULTS:Compared to baseline values, we found that cIMT decreased from 0.70 (0.50-1.10) mm to 0.60 (0.40-1.00) mm and PWV decreased from 9.52 ± 1.59 m/s to 9.16 ± 1.55 m/s in the 6th month of treatment (p < 0.001 and p < 0.001, respectively). The percentage decrease in cIMT (ΔcIMT) was 14.65 ± 11.88% and in PWV (ΔPWV) was 3.76 ± 4.08%. ΔcIMT was positively correlated with baseline cIMT, BMI and fat mass values (p = 0.019, p = 0.023 and p = 0.030, respectively). 1PWV was positively correlated with baseline systolic blood pressure (p = 0.020). CONCLUSIONS:According to the results of our study, dapagliflozin treatment reduces PWV and cIMT, and the decrease in these markers was greater among patients with higher baseline SBP, cIMT, BMI and fat mass. These results suggest that, if supported by more comprehensive studies, the cardiovascular benefits of dapagliflozin may be greater in patients with higher baseline cardiovascular risk.

Background: No-reflow (NR) is one of the serious complications of primary percutaneous coronary intervention (PCI) and it is related to higher short-and long-term mortality. In this study, we aim to determine NR possibility with a scoring system Methods: This retrospective, single-center study included consecutive patients diagnosed with acute ST-segment elevation myocardial infarction (STEMI) and treated by PCI, between May 2019 and May 2024. Results: A total 1050 patients were included: patients were divided to two groups according to the final coronary flow: NR group (n = 139) and control group (n = 930). CHADS(2)-VASc score was calculated for all the patients and multivariable regression and receiver operating characteristic curve analyses were conducted to determine the independent predictors of NR and cutoff value of CHA(2)D-VASc score. CHAD(2)-VASc cut-off values of 2 have a sensitivity of 84.2% and a specificity of 30% (The area under the curve (AUC) was calculated to be 0.615). Conclusion: A CHA(2)DS(2)-VASc score > 2 may serve as a valuable predictive tool for identifying the occurrence of NR in patients with STEMI. The sensitivity demonstrated in our study offers clinicians a practical approach for risk stratification and management of patients at risk of developing NR

Introduction: Cardiovascular disease affects millions of people, resulting in significant rates of morbidity and mortality. Inadequate healthcare systems, combined with costly treatments, impose a high economic burden, with growing challenges in the public healthcare arena. The demand for equitable access to specialised services is high in a country where most of the population relies on public healthcare services. Aim: This study investigated the shortcomings and possible solutions to expedite referral for appropriate diagnosis and therapy. Results: In a sub-analysis performed on 2 523 first-time echocardiography referrals to a tertiary-care hospital, cardiac abnormalities were diagnosed in 74% of patients. Most significant were valvular disorders (33%) and secondary pulmonary hypertension (19%). More than a third of patients presented with severe valvular disease, indicative of progressive heart disease and late referral. Almost a half (44%) of patients with cardiomyopathy presented with severely impaired left ventricular systolic function at first referral (left ventricular ejection fraction <30%), suggesting missed diagnosis and/or late referral. Conclusion: The study demonstrated a high demand for echocardiographic services from secondary regional and district hospitals in central South Africa. Late referrals can be attributed to long travelling distances and the number of regional hospitals. The availability of echocardiographic screening could fill the void in the current healthcare system to expedite diagnosis and effective referral.

Aim: Patients with type 2 diabetes mellitus (T2DM) who have suboptimal control of the triad of glucose (A), blood pressure (B) and lipid profile (C) have an increased risk of cardiovascular disease (CVD). Additionally, the presence of major depressive disorder (MDD) can lead to poor outcomes. Therefore, the aim of this study was to assess the role of MDD with ABC control in patients with T2DM in a South African private healthcare setting. Methods: Healthcare medical claims and electronic health records of 1 211 adult patients with T2DM and/or MDD were analysed for 2019. Results: Only 24% of the T2DM +/- MDD patients reached a low-density lipoprotein cholesterol (LDL-C) target < 1.8 mmol/l, and only 13% of the T2DM + MDD and 7.1% of T2DM-MDD patients achieved simultaneous ABC targets. The proportion of patients admitted due to macrovascular complications was higher in the T2DM + MDD group (22.8%) compared to the T2DM-MDD (13.1%) and MDD group (9.9%) (p = 0.012). Multivariate logistic regression analysis showed that older patients with T2DM + MDD achieved better glycated haemoglobin and LDL-C control. Significantly more patients with T2DM + MDD (12%) had repeat macrovascular admissions in 2019 compared to the T2DM-MDD patients (2.9%) (p = 0.005). Conclusion: Despite a managed-care environment, the comprehensive ABC control among patients with T2DM was suboptimal, particularly in those with MDD, placing them at greater risk for CVD events.

AIM:This study aimed to assess the prevalence of key cardiometabolic risk factors, including hypertension, obesity, dyslipidaemia and diabetes, among public school teachers in Vhembe district, Limpopo Province, South Africa. METHODS:A cross-sectional study design was employed, involving 201 public school teachers. Stratified random sampling was used to select teachers on the teachers' list obtained from the Department of Education. Anthropometric measurement variables, which included including body mass index (BMI), waist circumference (WC), and blood pressure (BP), were measured. Biochemical analyses included fasting blood profiles, measuring total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGL) and glucose levels. Statistical analyses were conducted using STATA 17, with a significance level set at p < 0.05. RESULTS:Obesity was observed in 43.7% of participants, with females demonstrating a significantly (P = 0.000) higher prevalence (62.5%) than males (20.2%). Additionally, 43.2% of participants presented with high-risk WC, with males (50.5%) being more affected than females (37.5%). Stage 1 systolic blood pressure hypertension was identified in 18.4% of participants, and 23.8% had diabetes. Dyslipidaemia was marked by elevated LDL, low HDL and increased triglyceride levels, with a higher prevalence in females. CONCLUSIONS:The findings indicate a substantial burden of cardiometabolic risk factors among teachers in the Vhembe district. Urgent implementation of targeted interventions, including health promotion, lifestyle modification, and routine health screenings, is imperative. Further research is needed to validate these findings across different regions in South Africa.

OBJECTIVES:Hypoxia and high-fat diet are independent risk factors for pulmonary vascular endothelial dysfunction (VED); however, their interactive effects are poorly understood. This study aimed to elucidate the effect and mechanism of hypoxia combined with a high-fat diet on the pulmonary arterial endothelial structure and function in rats. METHODS:Forty rats were randomly assigned to a normal diet and normoxia, a normal diet and hypoxia, a high-fat diet and normoxia, and a high-fat diet and hypoxia. Pulmonary morphology, pulmonary VED, and nitric oxide synthase (NOS) were evaluated. RESULTS:Compared to single factor, high-fat diet and hypoxia showed impaired vascular structure, reduced endothelium-dependent vasodilation, increased tissue factor, pulmonary NOS mRNA, peroxynitrite, and plasma malondialdehyde in rats. Hypoxic exposure also increased endothelial NOS (eNOS) and phosphorylated eNOS at threonine 495 in rats fed with a high-fat diet. CONCLUSIONS:Hypoxia combined with a high-fat diet aggravates pulmonary VED in rats, which may be associated with eNOS and nitric oxide (NO) dysfunction.

BACKGROUND:Acute coronary syndrome (ACS) is a leading cause of mortality worldwide, especially among young males. While the incidence of ACS decreases in older populations, it remains significant in younger individuals. This study aimed to identify clinical and biochemical differences between young ACS patients with critical atherosclerotic stenoses and those without. METHODS:The study retrospectively analyzed 55 normotensive patients aged 18-35 years diagnosed with ACS between January 2023 and January 2024. Patients were categorized as "critical" (≥70% stenosis) or "noncritical". Demographic, etiological, and biochemical parameters were compared. RESULTS:Critical coronary lesions were found in 32 patients (58%). Active smoking was significantly more common in the critical group (p = 0.048), and mean MPV was lower (p = 0.024). Logistic regression identified male gender (p = 0.026), CRP (p = 0.010), GGT (p = 0.021), and interventricular septum thickness (p = 0.043) as risk factors. CONCLUSION:This study underscores the importance of early detection and intervention in young ACS patients, particularly in addressing modifiable risk factors like smoking, inflammation, and oxidative stress. Further studies are needed to validate these findings.

INTRODUCTION:Partial anomalous pulmonary venous return (PAPVR) can be treated with either the single- or double-patch technique. In this study, we evaluated the results of both techniques in adult patients with PAPVR. METHODS:We reviewed the records of 29 patients treated for PAPVR in two groups, according to which surgical technique was used. RESULTS:Double- and single-patch repair techniques were performed in 12 (group 1) and 17 patients (group 2),respectively. In group 2, three patients with a distance of more than 10 mm between the ostium of the anomalous pulmonary vein and the cava-atrial junction needed surgical re-intervention because of superior vena cava stenosis. There was no sinus node dysfunction and no mortality in either group. CONCLUSION:In adult patients with PAPVR, the double-patch repair technique revealed better results than the single-patch technique, especially in patients with the ostium of the distal anomalous pulmonary vein more than 10 mm from the cava-atrial junction.

BACKGROUND:Transradial access (TRA) is a common technique used for diagnostic and interventional cardiac procedures. However, there are some challenges and risks of complications. This study aimed to evaluate the impact of periprocedural intermittent ischaemia of the contralateral arm on TRA and radial artery spasm. METHODS:We enrolled 80 patients with an indication for coronary angiography between December 2017 and June 2018. The patients were randomly grouped into two cohorts: intermittent contralateral arm ischaemia (n = 40) and control (n = 40) groups. RESULTS:The radial artery puncture success ratio was higher in the intermittent contralateral arm ischaemia group than in the control group (p = 0.025). In multivariable logistic regression analysis, intermittent contralateral arm ischaemia was significantly associated with radial artery puncture success (hazard ratio: 8.261, 95% confidence interval: 1.427-47.823, p = 0.018). CONCLUSION:Periprocedural intermittent contralateral arm ischaemia increased the radial intervention success due to the remote ischaemic preconditioning, vasodilator factors and autonomic nervous system role.

BACKGROUND:Postoperative cognitive dysfunction (POCD) following noncardiac surgery in the elderly is a growing concern. This study evaluates the relationship between carotid intima-media thickness (cIMT), a measure of subclinical atherosclerosis, and POCD. METHODS:In this prospective study, elderly patients (≥60 years) undergoing elective noncardiac surgery were divided into two groups based on cIMT. Cognitive assessments were conducted preoperatively and postoperatively using the mini-mental state examination, clock-drawing, digit span, trail-making, and Stroop tests. RESULTS:The study included 36 patients, with no significant differences in cognitive test outcomes between those with cIMT ≤0.9mmand >0.9mm. The overall incidence of POCD was 2.8%. CONCLUSIONS:Increased cIMT was not associated with a higher risk of POCD. Larger studies are necessary to confirm these findings.