Noncardiac surgery risky for older heart failure patients

When heart failure patients undergo surgery for other health problems, they are much more likely to die or suffer complications than similar patients who have coronary artery disease, according to a new study in the Oct. 6, 2004 issue of the Journal of the American College of Cardiology.

“Heart failure patients who undergo noncardiac surgery are at risk for complications and need to be followed closely through the surgery and after discharge. Also, we need to develop strategies to improve their care and understand how complications occur after surgery,” said Adrian F. Hernandez, M.D. at the Duke University Medical Center in Durham, N.C.

Using Medicare data from 1997 to 1998, the researchers looked at outcomes for 1,537 heart failure patients who underwent major surgery for problems unrelated to their heart disease. They compared the results for those patients with those for 1,757 patients with coronary artery disease and 44,512 patients who did not have heart disease. The patients had a variety of orthopedic, abdominal, thoracic, vascular and other types of surgeries.

After accounting for a variety of health factors and other characteristics, the researchers reported that 11.7 percent of the heart failure patients died within 30 days of major noncardiac surgery. By contrast, the 30-day death rate was 6.6 percent for coronary artery disease patients and 6.2 percent for patients in the control group. The risk of being readmitted to a hospital within 30 days was 20 percent for heart failure patients, 14.2 percent for coronary artery disease patients and 11 percent for control group patients.

Dr. Hernandez said the researchers did not expect to see that coronary artery disease patients appeared to fare just as well as patients from the general population.

“That was a surprise. Part of the reason may be the patients who make it into the operating room with coronary disease have had other procedures or received medications that lower their risk to that of the general population, such as revascularization procedures or beta blocker drugs. But there’s really no guidance about what to do for heart failure patients,” he said.

Dr. Hernandez said this study provides the best look yet at the national experience of heart failure patients.

“Prior studies have focused on the experiences in individual centers, so this effort was intended to get at the national experience, which is in the Medicare data,” Dr. Hernandez said. “This is a realistic view of what happens. It’s one of the strengths of this study that it takes a national view of what happens with these patients.”

He said he hopes the results will spur research into how to improve the odds for heart failure patients who need to undergo operations for everything from hip replacements to gall bladder removals.

“We need to update our understanding of what happens with heart failure during surgery. Our knowledge of heart failure has advanced over the last decade, but our understanding of heart failure in the surgical arena dates back more than 20 years. There are many factors such as inflammation, neurohormones and others that are now known to be important in heart failure which are also important in surgery. However, what happens with the combination of heart failure and surgery has not been updated with these modern concepts,” he said.

Because of the higher death and readmission rates seen in this study, Dr. Hernandez said that before surgery, during the procedure and through the recovery and follow-up period, heart failure patients need close attention from everyone on their health care team.

“Ensure that patients are well compensated before surgery; that is, their heart failure is stable and has not progressed in recent months. Secondly, after surgery, follow them closely to make sure they don’t have worsening heart failure. And the third thing is to have close follow up for their heart failure after they are discharged because of the high readmission rate. Also, for any patient about to have surgery, if there is any suspicion of heart failure, heart function should be evaluated,” he said.

Dr. Hernandez noted that although Medicare records offer a broad view, they lack important details, such as data on the other diseases the patients have, what medications they are getting and what previous procedures they have had. He said this study doesn’t reveal what factors influence whether a patient does well or not during and after surgery.

“However, even with those caveats, it would be hard to explain this huge difference in mortality and readmission rates between the heart failure patients and those with coronary disease,” Dr. Hernandez said.

Barry Massie, M.D., F.A.C.C., at the University of California San Francisco and the San Francisco VA Medical Center, who was not connected to this research, said this important article highlights the fact that relatively little is known about how to help heart failure patients get through major noncardiac surgery.

“The manuscript by Hernandez and coworkers is the first large study to examine the outcomes of heart failure patients who undergo noncardiac surgery. The results should bring new attention to this problem, because the mortality and morbidity rates of these patients are extremely high and dwarf those associated with coronary artery disease,” Dr. Massie said.