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LVEF, HF Symptoms, and Mortality After Surgery
Study Questions:
What is the association between heart failure (HF) among patients undergoing noncardiac surgery (NCS) and risk of postoperative morbidity and mortality? Previous investigations citing this relationship have been limited by small sample size, lack of systematic identification of acute HF symptoms, and/or lack of differentiation between patients according to left ventricular ejection fraction (LVEF).
Methods:
A cohort of 609,735 patients undergoing elective NCS between 2009-2016 in the Veterans Affairs (VA) Health System were examined retrospectively to determine the impact of HF, symptomatic HF, and HF stratified by LVEF, on 90-day postoperative all-cause mortality. HF cases were identified from the electronic medical record by entry of any HF diagnostic (International Classification of Diseases) code associated with either ≥1 hospitalization or ≥2 clinic visits within 3 years of surgery. Symptomatic HF involved presence of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, increased jugular venous distension, or pulmonary rales within 30 days of surgery. LVEF was categorized as preserved (>50%), mildly reduced (40-49%), moderately reduced (30-39%), or severely reduced (<30%). Secondary outcomes were 30-day and 1-year mortality, with post hoc analysis of numerous outcomes including myocardial infarction, bleeding events, and prolonged length of hospital stay. Surgical procedures were stratified by invasiveness using the three-level VA Surgical Complexity Matrix.
Results:
HF was identified in 7.9% of the population, and was associated with fourfold greater risk of 90-day postoperative mortality, regardless of LVEF or symptom status, with 5.49% versus 1.22% crude mortality rates in patients with versus without HF; the association was partially attenuated but remained significant after adjustment for numerous factors including surgical complexity and various demographic and comorbid conditions. Among patients with HF, reduced LVEF progressively increased risk, with primary outcome affecting 6.58% and 8.34% of patients with moderate and severely reduced LVEF, compared to 4.88% of HF patients with LVEF >50%. Among the 12% of HF patients identified as symptomatic within 30 days of surgery, the 90-day postoperative crude mortality rate was 10.11%, more than double the 4.84% rate observed among patients with asymptomatic HF. The observed 90-day mortality rate in patients with symptomatic HF plus severe LVEF was even higher, at 14.91%. HF conferred highest attributable risk in low-risk (standard) surgical procedures, with 90-day mortality of 4.62% compared to 0.66% 90-day mortality in patients without HF. Although high-risk (complex) surgical procedures more than doubled the 90-day mortality rate among patients with HF (10.34%), the event rate increased more than ninefold (6.19%) among patients without HF. Secondary outcome patterns followed similar trends, and numerous outcomes including bleeding events and prolonged length of hospital stay were more frequent among patients with HF.
Conclusions:
This large cohort study demonstrates that HF significantly and independently increases risk of 90-day postoperative mortality, overall mortality, and nonfatal complications, even after low-risk surgical procedures. Mortality is substantially greater when HF is symptomatic, and risk increases progressively with greater impairment of LVEF. Although mortality is greater after complex surgery, even low-risk surgery carries significant mortality risk in patients with HF.
Perspective:
The significantly poorer postoperative outcomes observed among patients with symptomatic or decompensated HF suggests that preoperative optimization efforts may constitute a valuable opportunity for risk reduction in this population. The role of the echocardiogram in the immediate preoperative period to refine the risk stratification or clinical decision-making process among asymptomatic patients with a history of HF, or with suspected HF, warrants further investigation.
Keywords: Ambulatory Care, Dyspnea, Dyspnea, Paroxysmal, Echocardiography, Electronic Health Records, Heart Failure, Hemorrhage, Length of Stay, Myocardial Infarction, Risk Factors, Stroke Volume, Elective Surgical Procedures, Ventricular Function, Left, Veterans
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