Even Mild Heart Failure May Boost Complications, Deaths After Ambulatory Surgery

By Marilynn Larkin

July 17, 2019

NEW YORK (Reuters Health) - Heart failure with or without symptoms was associated with an increased risk of 30-day postoperative complications and 90-day mortality in a retrospective study of patients undergoing ambulatory surgery.

"For the majority of surgeons, internists, and anesthesia physicians I think the findings will be a surprise, since outpatient surgical procedures are considered very low risk for death," Dr. Sherry Wren of Stanford University School of Medicine in Palo Alto told Reuters Health by email. However, "as more patients get outpatient procedures, the number of patients with substantial co-morbid medical conditions also increases."

"I think this study should change practice," she said. 'It helps risk stratify patients and guide pre- operative discussions and informed consent."

As reported online July 10 in JAMA Surgery, Dr. Wren and colleagues analyzed data from the Veterans Affairs Surgical Quality Improvement Project database for 355,121 patients who underwent ambulatory, elective noncardiac surgery from 2009 to 2016, including one year of follow-up.

Outcome data were available from 19,353 patients with heart failure (5.5%; mean age, 67.9; 96.9% men) and 334,768 without heart failure (mean age, 57.2; 90% male).

The heart failure group had higher 90-day mortality compared with those without heart failure (crude risk, 2.00% vs. 0.39%; adjusted odds ratio, 1.95). The mortality risk increased progressively with decreasing systolic function and was greater for both symptomatic (crude risk, 3.57%; aOR, 2.76) and asymptomatic (crude risk, 1.85%; aOR, 1.85) heart failure patients.

Further, heart failure patients had a higher 30-day complication rate (crude risk, 5.65% vs. 2.65%; aOR, 1.10).

Dr. Wren said, "Overall, outpatient surgery and its outcomes are woefully understudied in the U.S., especially in light of the near 30 million cases per year. I think the effects outside the US would be similar in high-resource countries where patients have medical management of heart failure. In low-resource nations, I think the mortality would be even greater."

Heart failure specialist Dr. Paul Hauptman, Dean and Professor of Medicine at the University of Tennessee Graduate School of Medicine in Knoxville, told Reuters Health by email, "The methodology is sound, though direct causation is hard to establish. Nevertheless, these findings confirm what Lee Goldman initially described in a landmark 1977 study, before the introduction of life-extending therapy for heart failure."

That study, published in The New England Journal of Medicine (http://bit.ly/2YZuJRi), proposed a "multifactorial index" to estimate cardiac risk preoperatively, regardless of whether there was a direct surgical risk.

"In a time when patients have significant comorbidities, and surgeries are frequently occurring in ambulatory settings, the current study highlights the need for increased rigor in the assessment of patients undergoing surgery in order to maximize the safe delivery of medical care," Dr. Hauptman concluded.

SOURCE: http://bit.ly/2Z2zuJT

JAMA Surgery 2019.