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Durham, NC - Patients with heart failure undergoing noncardiac surgery have much worse outcomes than patients with coronary disease, a new study shows. The findings, published in the October 6, 2004 issue of the Journal of the American College of Cardiology, show that heart-failure patients had mortality rates after noncardiac surgery that were twice as high as those for patients with coronary disease.1
The authors, led by Dr Adrian Hernandez (Duke Clinical Research Institute, Durham, NC), explain that there is a lack of generalizable outcome data on heart-failure patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients.
To study this group further, Hernandez et al used a Medicare database known as the standard analytic filea random sample of 5% of the Medicare beneficiaries that includes all in-patient hospitalizations that are billed to Medicare and documents limited clinical information such as age, gender, race, and discharge status, including death. They identified patients with heart failure who underwent major noncardiac surgery and patients with coronary artery disease. All other remaining patients (controls) who had similar surgery served as reference groups.
There were 23340 heart-failure patients and 28710 coronary-disease patients in the sample, and around 6% of both these groups underwent major noncardiac surgery. There were 44512 control patients who underwent major noncardiac surgery.
After accounting for demographic characteristics, type of surgery, and comorbid conditions, both the death rate and the 30-day readmission rate was significantly higher for the heart-failure patients than for the coronary-disease patients or the controls. Indeed, the coronary-disease patients had similar mortality to the controls.
The higher mortality for heart-failure patients was apparent across all types of surgeries.
Risk-adjusted operative mortality and 30-day readmission rates|
Outcome |
Heart failure (%) |
Coronary disease (%) |
Control (%) |
|
Operative mortality (death before discharge or within 30 days of surgery) | 11.7 | 6.6 | 6.2 |
|
30-day readmission rate | 20 | 14.2 | 11.0 |
The researchers say these results are especially important as more than 75% of all heart-failure patients are older than 65 and have the highest incidence of major noncardiac surgeries. They add that previous studies have demonstrated that heart failure is an important risk factor, but the magnitude may have been underappreciated.
Hernandez et al point out that testing and interventions for coronary disease often delay surgery for weeks, but that the similarity in mortality between CAD patients without heart failure and the general population in this study supports the notion that these patients do not routinely need additional testing, whereas heart-failure patients do.
"Our study demonstrates that the presence of heart failure substantially increases the risk of mortality... . Therefore, evidence-based strategies are needed for constructing recommendations in professional guidelines to manage heart-failure patients perioperatively," the researchers comment.
"Heart-failure patients who present for urgent or emergent procedures are high risk, and procedures to quickly identify their level of compensation and optimize their heart failure before undergoing a major surgery need to be identified," they add.
Better in-hospital surveillance needed
Noting the 20% readmission rate for heart-failure patients in this study, Hernandez et al say: "There appears to be an important need for surveillance of patients with a history of heart failure in the hospital to ensure that discharge is appropriate, plus close follow-up of outpatients to prevent readmissions. A multidisciplinary approach may prevent readmissions, ensure appropriate medication use, and hopefully prevent excess mortality."
They argue that more work needs to be done to identify those heart-failure patients at the highest risk and to intervene to reduce the risk, adding that there are few procedures that cannot be delayed to stabilize heart failure. But they also say that elective surgery in heart-failure patients should not be unduly delayed until absolutely necessary, as this would cause more urgent procedures to be performed.
The researchers note that this study raises the question of what transpires perioperatively in heart-failure patients beyond ischemia from underlying coronary disease. They add that heart failure with preserved systolic function, which is particularly common in the elderly, may be important in the perioperative setting because of poor tolerance to volume overload, a common perioperative event.
How to reduce the risk?
Hernandez and colleagues say that future studies need to address how to reduce these risks for heart-failure patients. They suggest that these should include more extensive studies of beta blockers, statins, and angiotensin-aldosterone antagonism.
"Although the long-term benefit of beta blockers is established in heart-failure patients, several issues may arise over the short term when attempting to titrate beta blockers over a few days as opposed to several weeks, as is normally done in outpatient management," they comment.
Future work should also clarify the role of right catheterization of advanced heart-failure patients in the perioperative setting, as there is little evidence for this procedure despite some recommendations, they conclude.
