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Heart Failure and Risk of Mortality

As early as 1977 the Goldman Risk Index identified the presence of heart failure physical examination signs (jugular venous distension and S3 gallop) as two of nine variables associated with an increased risk of cardiac complications in noncardiac surgery.1 The Goldman Risk Index was revised in 1999 to facilitate ease of use and increased accuracy. This Revised Cardiac Risk Index (RCRI), still in popular use today, considers a “history of congestive heart failure” as one of the six predictors of perioperative cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest.2 Despite advances in the treatment of heart failure since 1999, preexisting heart failure before noncardiac surgery continues to be a marker of increased perioperative risk that is often underestimated. In a large Canadian cohort of 38,047 patients undergoing noncardiac surgery, the unadjusted 30-day postoperative mortality was significantly higher in patients with preexisting nonischemic and ischemic heart failure, than in those with preexisting atrial fibrillation and coronary artery disease (Table 11-1).3 The higher risk was observed even in minor risk procedures. In a study of 1,172,632 patients undergoing noncardiac surgery, 7,544 (0.64%) had preexisting heart failure. The group with heart failure was more likely to require cardiopulmonary resuscitation and ventilator support for more than 48 hours, and experienced higher rates of 30-day mortality, readmission to the hospital, and myocardial infarction (Table 11-2).4 In a large retrospective cohort of 609,735 Veteran's Affairs patients, 47,997 (7.87%) had preexisting heart failure. The 90-day postoperative mortality was significantly higher in those with heart failure compared to those without. Furthermore, the lower the ejection fraction, the higher the mortality (Table 11-3).5 Despite the association of heart failure with postoperative mortality, after multivariable regression analysis, heart failure itself was not the clinical cause of mortality, but rather served as a marker for a multitude of comorbidities that heart failure patients typically have. Patients with heart failure were older and had more coexisting conditions.

TABLE 11-1Preoperative Conditions and Associated 30-Day Mortality (%) in 38,047 Patients Undergoing Noncardiac Surgery3
TABLE 11-21,172,632 Patients Undergoing Noncardiac Surgery, of which 7,544 (0.64%) had Preexisting Heart Failure4

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