Heart failure affects more than five million Americans and is one of the major causes of hospitalization in patients over 65 years of age. The number of patients with chronic heart failure will increase as Americans live longer. Additionally, patients with heart failure are living longer through medical advances. As we age, the chance of surgery increases, so anesthesiologists will see an increased number of patients with chronic heart failure.
Is new or worsening heart failure associated with a greater likelihood of 30-day morbidity and mortality? Dr. Michael D. Maile, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, and colleagues used the 2005-2012 American College of Surgeons National Surgical Quality Improvement Program participant use data file to compare 30-day mortality, and the incidence of 30-day morbidity related to a variety of organ systems for over 5,000 patients with worsening heart failure undergoing nonemergent, noncardiac surgery compared with a similar number of control group patients. The results of this analysis are published in this month’s issue of Anesthesia & Analgesia in the article titled “Worsening Preoperative Heart Failure Is Associated with Mortality and Noncardiac Complications, But Not Myocardial Infarction After Noncardiac Surgery: A Retrospective Cohort Study.”
Both groups of patients had a high incidence (86%) of hypertension. About half had preoperative dyspnea, diabetes, and a history of cardiac surgery or percutaneous coronary intervention. Compared with the matched control group, patients with heart failure were about twice as likely to die within 30 days of surgery. Patients with heart failure also had a 40-70% increased risk for postoperative complications, particularly respiratory (unplanned tracheal intubation, need for prolonged mechanical ventilation, and pneumonia), renal (renal insufficiency and acute renal failure), and infectious complications (sepsis, urinary tract infection, and pneumonia). The risk of myocardial infarction was the same for both groups. The incidence of cardiac arrest within 30 days of surgery was slightly increased in the heart failure patients.
As noted by Drs. W. Scott Beattie, Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada, and Duminda N. Wijeysundera, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada, in the accompanying editorial titled “The Growing Burden of Perioperative Heart Failure,” this “…study draws attention to the as yet unappreciated high incidence of noncardiac complications as well. Increased rates of sepsis and pneumonia are key and novel findings…The report by Maile et al. draws attention to the urgent need for hospitals, and practitioners, to adopt systematic processes of care and conduct research to ameliorate this unacceptably high rate of postoperative complications for patients with HF…the early postoperative course should be conducted in high-acuity nursing environments, with requisite assessment of cardiac biomarkers (troponin and brain natriuretic peptide). Finally, do not be lulled into a false sense of security by the preoperative demonstration of preserved LV function.”