Heart failure makes surgery more risky, even without symptoms

(Reuters Health) – An American study even suggests that patients with relatively healthy heart failure are more likely to die after surgery than people with a healthier heart.

For patients with heart failure with obvious symptoms, surgery has long been badociated with an increased risk of complications and death. But the current study offers new evidence that even patients with heart failure without symptoms present an increased risk of mortality, said Dr. Sherry Wren, lead author of the study, Vice President of Surgery at the Stanford University School of Medicine and Chief of the General Surgery Department of Palo Alto Veterans Health Care System.

The researchers badyzed 90-day surgical mortality rates for nearly 48,000 patients with heart failure and nearly 562,000 patients without heart failure. None of them has undergone emergency surgery or cardiac surgery.

During the study, 2,635 people with heart failure, 5.5%, died within 90 days of surgery, as well as 6,881 patients without heart failure, or 1.2%.

The study found that patients with symptomatic heart failure were more than twice as likely to die as people without heart failure. Asymptomatic heart failure patients were still 53% more likely to die.

"All surgical decisions involve risk compromises and benefits, and in many cases, the benefits outweigh the risks and the surgery should take place," Wren said via e-mail.

While doctors and patients should already discuss the risks and benefits, the results of the current study should help these conversations become more nuanced, especially for patients with asymptomatic heart failure, Wren said.

Heart failure occurs when the heart muscle is too weak to pump enough blood into the body. Symptoms may include fatigue, weight gain due to water retention, shortness of breath and coughing or wheezing.

Heart failure patients may also develop what is known as a left ventricular ejection fraction or a reduced capacity of the main pumping chamber of the heart to expel oxygenated blood from the heart into the rest of the body.

In the study, even patients with heart failure without symptoms and with a normal ejection fraction had 46% more risk of dying after surgery than people without heart failure.

Heart failure patients were more likely to be men, obese, white, and older – an average age of 69 years, compared to 59 years for people without heart failure. They also tended to have more complex chronic health problems than people without heart failure.

Patients with heart failure also underwent more complex operations than people without heart failure.

One of the limitations of the study, published in JAMA, is that long-term survival rates may be different from the 90-day results examined in the study.

Even in this case, the results confirm that all patients with heart failure should be cautious when they approach elective surgery and ensure that they are managing their disease as much as possible before their operations, a said Dr. Amrut Ambardekar, a cardiology researcher at the University of Colorado, Anschutz Medical. Campus in Aurora, who did not participate in the study.

"Patients with heart failure can be treated to (stabilize) their symptoms; however, the stress of an operation can tip that balance, "Ambardekar said by e-mail.

"Elective surgeries can stress the body due to anesthesia, the administration of fluids, surgical bleeding and / or the addition of new medications. These stressors can destabilize a patient with heart failure even if his symptoms were well controlled before surgery. "

In some cases, patients with heart failure who have symptoms or whose pumping capacity is reduced may wish to delay an elective surgery, said Dr. Clare Atzema of the University of Toronto and Sunnybrook. Research Institute.

"If the surgery can be delayed, it may be time to stabilize heart failure with drugs (and therefore reduce the risk side of the equation)," said Atzema, who did not participate in the study, by e-mail. "Patients who want to have surgery need to know it quickly.

SOURCE: bit.ly/2IaB4Fs JAMA, online February 12, 2019.