Mortality and Readmission of Patients With Heart Failure, Atrial Fibrillation, or Coronary Artery Disease Undergoing Noncardiac Surgery

Abstract

Background— The postoperative risks for patients with coronary artery disease (CAD) undergoing noncardiac surgery are well described. However, the risks of noncardiac surgery in patients with heart failure (HF) and atrial fibrillation (AF) are less well known. The purpose of this study is to compare the postoperative mortality of patients with HF, AF, or CAD undergoing major and minor noncardiac surgery. Methods and Results— Population-based data were used to create 4 cohorts of consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta, Canada. The main outcome was 30-day postoperative mortality. The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P <0.0001). Among patients undergoing minor surgical procedures, the 30-day postoperative mortality was 8.5% in NIHF, 8.1% in IHF, 2.3% in CAD, and 5.7% in AF ( P <0.0001). After multivariable adjustment, postoperative mortality remained higher in NIHF, IHF, and AF patients than in those with CAD (NIHF versus CAD: odds ratio 2.92; 95% confidence interval 2.44 to 3.48; IHF versus CAD: odds ratio 1.98; 95% confidence interval 1.70 to 2.31; AF versus CAD: odds ratio 1.69; 95% confidence interval 1.34 to 2.14). Conclusions— Although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD, and even minor procedures carry a risk higher than previously appreciated.

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

“…27) Many trials have sought prognosticating factors in noncardiac surgery. 4,5,6,10,21,22,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] In these studies, poor functional capacity, recent MI and unstable angina, decompensated heart failure, significant arrhythmia, diabetes mellitus, renal insufficiency, cerebrovascular disease, advanced age, tachycardia, anemia, surgical kind, and elevated troponin-I level were determined to be independent prognostic factors after noncardiac surgery, most of which were in agreement with our study. While the results of those studies had been generated after short-term follow-up, the present study extended the follow-up period to 7 years and attempted to provide valuable data regarding longer term mortality.…”

Association of Atrial Fibrillation and Oral Anticoagulant Use With Perioperative Outcomes After Major Noncardiac Surgery

“…To avoid incomplete medication records, we excluded participants without at least 1 year of eligibility for prescription drug coverage through the Ontario Drug Benefit. Fourteen prespecified major noncardiac surgeries were included: abdominal aortic aneurysm repair, carotid endarterectomy, peripheral vascular surgery, femur and hip surgery, knee replacement, lung resection, gastrectomy or esophagectomy, bowel and rectal surgery, liver resection, pancreaticoduodenectomy, abdominal hysterectomy, radical prostatectomy, nephrectomy, and cystectomy 9, 10. In the event of multiple surgeries performed during the study period, only the first qualifying surgery was used as the index procedure.…”

Peri-operative Cardiovascular Risk and the General Internist

“…9 Although the observed mortality rate may have been elevated by addressing a slightly older population and by including patients undergoing emergent or urgent procedures, as well as some critically ill inpatients, the 4-week post-procedural mortality rates in heart failure and atrial fibrillation patients undergoing strictly outpatient minor procedures (such as colonoscopy or cystoscopy) were still in excess of 4% and 2%, respectively. Mortality rates were particularly high for those patients undergoing surgery within 4 weeks of an incident diagnosis of heart failure or atrial fibrillation.…”

“…Active cardiac conditions, including CHF and atrial fibrillation, should be stabilized if possible for a month or more prior to elective surgery. 9 We should focus our preoperative consultations and interventions on those individuals most likely to benefit, and therefore continue to follow the ACC/AHA guidelines, forgoing preoperative cardiac evaluation of low-risk patients without active cardiac conditions who also have >4 METS exercise capacity, low risk scores and surgery types, and no co-morbidities requiring control preoperatively. Patients undergoing emergent or urgent surgery may benefit from consultation for management of acute issues, but are unlikely to benefit from an extensive preoperative riskstratification process.…”