ORIGINAL ARTICLE
Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery

https://doi.org/10.4065/83.3.280Get rights and content

OBJECTIVE

To evaluate modern surgical outcomes in patients with stable heart failure undergoing elective major noncardiac surgery and to compare the experience of patients with heart failure who have reduced vs preserved left ventricular ejection fraction (EF).

PATIENTS AND METHODS

We retrospectively studied 557 consecutive patients with heart failure (192 EF ≤40% and 365 EF >40%) and 10,583 controls who underwent systematic evaluation by hospitalists in a preoperative clinic before having major elective noncardiac surgery between January 1, 2003, and March 31, 2006. We examined outcomes in the entire cohort and in propensity-matched case-control groups.

RESULTS

Unadjusted 1-month postoperative mortality in patients with both types of heart failure vs controls was 1.3% vs 0.4% (P=.009), but this difference was not significant in propensity-matched groups (P=.09). Unadjusted differences in mean hospital length of stay among heart failure patients vs controls (5.7 vs 4.3 days; P<.001) and 1-month readmission (17.8% vs 8.5%; P<.001) were also markedly attenuated in propensity-matched groups. Crude 1-year hazard ratios for mortality were 1.71 (95% confidence interval [CI], 1.5-2.0) for both types of heart failure, 2.1 (95% CI, 1.7-2.6) in patients with heart failure who had EF ≤40%, and 1.4 (95% CI, 1.2-1.8) in those who had EF >40% (P<.01 for all 3 comparisons); however, the differences were not significant in propensity-matched groups (P=.43).

CONCLUSION

Patients with clinically stable heart failure did not have high perioperative mortality rates in association with elective major noncardiac surgery, but they were more likely than patients without heart failure to have longer hospital stays, were more likely to require hospital readmission, and had a substantial long-term mortality rate.

Section snippets

PATIENTS AND METHODS

Preoperative evaluation at the Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center at the Cleveland Clinic involves a complete history and physical examination, detailed risk assessment and perioperative risk stratification, and clinical management by a hospitalist. If signs of decompensated HF are apparent during the evaluation, therapies are initiated to optimize volume status, and, if appropriate, cardiac status is reevaluated (with echocardiography, stress

RESULTS

A total of 596 potentially eligible patients with HF were identified who were monitored for a median of 1.9 years after surgery. Thirty-nine patients (6.5%) were excluded because they had no LV imaging studies to document EF. Two more patients were excluded because of severe valvular heart disease. The mean ± SD interval between the cardiac imaging study and the subsequent surgery was 1.8±0.44 years. Finally, a total of 557 patients with HF (192 with EF ≤40% and 365 with EF >40%) and 10,583

DISCUSSION

Our data suggest that perioperative mortality is surprisingly low (<2%) in patients with clinically stable HF—regardless of EF—undergoing elective noncardiac surgery. At 1 year, crude mortality rates for patients with HF with reduced EF (13.5%) or with preserved EF (6.3%) were significantly higher than for controls (3.1%). However, we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months. This

CONCLUSION

Our data suggest that patients with clinically stable HF undergoing elective major noncardiac surgery—regardless of EF—can have low perioperative mortality rates, but they are more likely than patients without HF to have longer hospital stays, require hospital readmission, and have a substantial long-term mortality rate.

REFERENCES (31)

  • AF Hernandez et al.

    Outcomes in heart failure patients after major noncardiac surgery

    J Am Coll Cardiol

    (2004)
  • S Yusuf et al.

    Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial

    Lancet

    (2003)
  • EH Blackstone

    Comparing apples and oranges

    J Thorac Cardiovasc Surg

    (2002)
  • CJ DeFrancis et al.

    2004 national hospital discharge survey

    Adv Data

    (2006 May)
  • L Goldman et al.

    Multifactorial index of cardiac risk in noncardiac surgical procedures

    N Engl J Med

    (1977)
  • TH Lee et al.

    Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery

    Circulation

    (1999)
  • DW Kitzman et al.

    Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure

    JAMA

    (2002)
  • MM Redfield et al.

    Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic

    JAMA

    (2003)
  • TE Owan et al.

    Trends in prevalence and outcome of heart failure with preserved ejection fraction

    N Engl J Med

    (2006)
  • RS Bhatia et al.

    Outcome of heart failure with preserved ejection fraction in a population-based study

    N Engl J Med

    (2006)
  • LA Fleisher et al.

    ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery

  • DC Goff et al.

    Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project

    Arch Intern Med

    (2000)
  • PA McKee et al.

    The natural history of congestive heart failure: the Framingham Study

    N Engl J Med

    (1971)
  • JS Gottdiener et al.

    Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function: the Cardiovascular Health Study

    Ann Intern Med

    (2002)
  • LR Pasternak

    Preoperative assessment: Guidelines and challenges

    Acta Anaesthesiol Scand Suppl

    (1997)
  • Cited by (0)

    Dr Phillips is supported by a Supplement 3 R01 HL080228-01S1 from the National Heart, Lung and Blood Institute of the National Institutes of Health, Bethesda, MD.

    View full text