University of Virginia Health System

Heart Failure a Concern for Non-Cardiac Surgeries

Older people with heart failure face heightened odds of complications and death after non-cardiac surgeries, according to a study reported in the medical journal Anesthesiology.

Heart failure, the progressive loss of the heart's ability to pump blood, is widespread among older Americans but sometimes overlooked as a risk factor when surgery is needed, he says.

"Most physicians focus on whether [older patients] have coronary artery disease or have a risk of heart attack," says Hernandez. "Heart failure is by far a more important risk factor, but it doesn't usually have greater weight when they want to identify patients at risk of complications or consider how they want to treat them after surgery."

Symptoms of heart failure include shortness of breath, fatigue and swelling of the legs.

"This agrees with several previous studies showing heart failure is an adverse condition for surgical procedures," says James Bergin, M.D., Professor of Medicine and Medical Director of the Heart Failure/Cardiac Transplantation program at the University of Virginia Health System. "What is helpful is that the database is very large. I am uncertain, however, as to what definition of heart failure was used."

Condition Has Impact on Surgery Success

Hernandez used Medicare data on more than 159,000 people undergoing major surgery not involving the heart, such as hip replacement operations. The study was the largest conducted on this issue.

Past estimates have put the incidence of heart failure in older people between 5 percent and 12 percent, but the new study found the condition in almost 20 percent of surgery patients.

The study divided the participants into three groups: those with heart failure, with or without coronary artery disease; those with only coronary artery disease; and those with neither condition.

Nearly 98 percent of surgery patients were discharged from the hospital shortly after their procedure.

But 17.1 percent of patients with heart failure had to be re-hospitalized within 30 days, compared with 10.8 percent of patients with coronary artery disease and just 8.1 percent of patients with neither ailment.

In the month after having surgery, 1.6 percent of heart-failure patients died, compared with 0.5 percent of coronary artery disease patients and 0.3 percent of patients with neither condition.

Steps can be taken to reduce death rates, notes Hernandez.

"The first thing is to check on what the conditions are that might influence the patients' outcomes," he says. "We have to identify therapies that lower the risk of a poor outcome and assure that all patients, when they have surgery, are carefully monitored."

Close attention should be paid to be sure that symptoms of heart failure are kept to a minimum, adds Hernandez. Medications such as beta blockers and diuretics can be used to keep heart failure under control.

But he notes that it is not certain how effective such measures might be in reducing risks - only a rigorous, controlled study could answer that question definitively.

Steps Can Be Taken to Reduce Risks

Dr. Robert Hobbs, a cardiologist at the Cleveland Clinic, says the increase in surgery risk due to heart failure has been noted before, but "this is a big study that involves a lot of people. It solidifies that the risk is real, and the risk is substantial."

Measures that can be taken to reduce the risk include simply not performing surgery, if possible, on someone whose life might be endangered, says Hobbs.

For some patients with heart failure, however, having surgery may be worth the risk, says UVA's Bergin. 

"For example, even if the death rate is higher in the heart failure group, it still may make sense [to perform surgery] if the majority of the patients would die without the surgery or would have a poor quality of life," he says.

If surgery is performed, Hobbs says, extra precautions should be taken. 

"If surgery is necessary for someone with heart failure, there should be targeted use of heart-failure medications before the operation and an effort to avoid overloading the body with intravenous fluid during the procedure," he says.

"And we would certainly watch them more carefully in the postoperative period," adds Hobbs.

Learn more about heart failure - and UVA's Heart and Vascular Center - at www.uvahealth.com.

Women can learn more about their unique risks for heart disease - and how to better manage those risks - through Live Red, a new UVA heart-health initiative. You'll learn how heart attack symptoms can be different for women than for men, and you can take an online risk assessment to learn your personal heart disease risk factors.

There, you can sign up for Club Red, our free heart-healthy club for women. Benefits include tips from UVA healthcare providers and a gift package to help you live red in style.

Always consult your physician for more information.