INTRODUCTION — Patients with heart failure (HF) are at increased risk for major adverse cardiac events with noncardiac surgery. Patients with or without a prior diagnosis of HF may decompensate with acute HF perioperatively. (See 'Epidemiology' below.)
HF is a clinical syndrome characterized by the presence of one or more current or prior symptoms (such as dyspnea, fatigue, or edema) caused by cardiac dysfunction. This definition of HF includes patients with American College of Cardiology/American Heart Association stages C and D HF and excludes patients in stages A (at risk for HF but without structural heart disease) or B (at risk for HF with structural heart disease) [1] (table 1). (See "Determining the etiology and severity of heart failure or cardiomyopathy", section on 'Definition'.)
Management of perioperative HF includes preoperative evaluation and risk assessment, decision-making regarding whether and when to proceed with surgery, and pre-, intra-, and postoperative management [2,3]. Preoperative and postoperative evaluation and management for patients with HF or at risk for HF are reviewed here.
Related issues are discussed separately:
●Intraoperative management during noncardiac surgery for patients with HF. (See "Intraoperative management for noncardiac surgery in patients with heart failure".)
●General management approaches for patients with acute and chronic HF. (See "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Specific therapies" and "Overview of the management of heart failure with reduced ejection fraction in adults" and "Treatment and prognosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with mid-range ejection fraction".)
●Management of patients with valve disease undergoing noncardiac surgery. (See "Noncardiac surgery in adults with aortic stenosis" and "Noncardiac surgery in patients with mitral or aortic regurgitation" and "Rheumatic mitral stenosis: Overview of management" and "Anesthesia for noncardiac surgery in patients with aortic or mitral valve disease" and "Rheumatic mitral stenosis: Overview of management", section on 'Management of noncardiac surgery'.)
EPIDEMIOLOGY — HF is one of the most common conditions requiring evaluation and treatment in patients undergoing noncardiac surgery. Aging populations and progress in the treatment of chronic diseases such as hypertension, diabetes mellitus, and coronary artery disease (CAD) are increasing the prevalence of HF [4]. In addition, older adult patients at risk for HF are undergoing noncardiac surgery at increasing rates. It is estimated that HF is present in almost 20 percent of older adults undergoing common surgical procedures in the United States [5].
HF is a major risk factor for adverse cardiac events, including death following noncardiac surgery [6]. Data suggest that patients with chronic HF are at higher risk for major adverse cardiac events following noncardiac surgery than patients with CAD [5,7].
●For major procedures, patients with chronic HF are at greater risk of mortality than patients with CAD or with neither of these conditions. In an analysis based upon Medicare files from 1997 and 1998 that included 23,340 patients with HF and 28,710 patients with CAD who underwent major noncardiac surgery, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was 11.7 percent for patients with HF, 6.6 percent for patients with CAD, and 6.2 percent for control patients [8]. The risk-adjusted 30-day readmission rate was 20.0 percent for HF, 14.2 percent for CAD, and 11.0 percent for control patients. A population-based data analysis of four cohorts with a total of 38,047 consecutive patients showed that the 30-day postoperative mortality rate following major or minor procedures was significantly higher in patients with nonischemic HF (9.3 percent), ischemic HF (9.2 percent), and atrial fibrillation (6.4 percent) than in those with CAD (2.9 percent) [7].
●For minor procedures also, HF is an independent risk factor for morbidity and mortality [7,9-11].
●Patients with new-onset, worsening, or acute decompensated HF are at particularly high risk for perioperative morbidity and mortality [12].
The assessment of risk in individual patients with HF is discussed below. (See 'Assessing risk' below.)
PREOPERATIVE EVALUATION — The general evaluation of cardiac risk prior to noncardiac surgery includes evaluation for HF. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
Goals — The goals of a comprehensive evaluation for HF prior to noncardiac surgery include:
●Identifying patients with known or suspected HF. For patients with suspected HF, a diagnostic evaluation is performed to determine whether HF or another condition is present. (See "Heart failure: Clinical manifestations and diagnosis in adults".) (Related Pathway(s): Heart failure: Diagnosis and classification.)
●For patients with HF:
•Determining whether patients with HF are stable and optimally managed or show symptoms or signs of decompensation. (See 'Clinical evaluation' below and 'Preoperative tests' below and "Determining the etiology and severity of heart failure or cardiomyopathy" and "Approach to diagnosis and evaluation of acute decompensated heart failure in adults".)
•Recognizing high-risk HF syndromes, including acute HF (new onset or decompensated), advanced HF (identified by presence of severe symptoms that interfere with daily life despite optimized evidence-based therapy), and HF with very low left ventricular ejection fraction (LVEF <30 percent). (See "Approach to diagnosis and evaluation of acute decompensated heart failure in adults" and "Clinical manifestations and diagnosis of advanced heart failure".)
•Identifying comorbidities that may impact the stability of HF in the postoperative period. (See 'Assessing risk' below.)
●Identifying patients with no history or symptoms of HF but at risk for developing HF in the perioperative period.
Clinical evaluation — The initial step in preoperative evaluation is an assessment of symptoms and signs of HF, functional status, conditions associated with risk of acute decompensated HF, and conditions associated with risk of developing HF. (See "Heart failure: Clinical manifestations and diagnosis in adults".)
●Symptoms and signs of HF include exertional dyspnea, fluid retention, and fatigue. In older adults, the diagnosis of early or even more advanced HF may not be made in a timely manner since these patients often lead a fairly sedentary life due to their age and other debilitating noncardiac problems. Since symptoms of HF are not specific to HF, careful physical examination and in some cases, testing is required to differentiate HF from other causes of dyspnea such as obesity, deconditioning, and lung disease. (See "Heart failure: Clinical manifestations and diagnosis in adults", section on 'Differential diagnosis'.)
Physical signs that suggest HF or cardiomyopathy include resting tachycardia, elevated jugular venous pressure, displaced apical impulse, third and/or fourth heart sound, and murmur of mitral regurgitation (table 2). (See "Heart failure: Clinical manifestations and diagnosis in adults", section on 'Physical examination'.)
●Functional status is usually estimated from the patient’s description of daily activities. One study from Seattle showed that a self-reported inability to walk four blocks (an average block length in that city is approximately 100 meters) and climb two flights of stairs without experiencing symptomatic limitation was 71 percent sensitive and 47 percent specific for serious postoperative complications [13]. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Initial preoperative evaluation'.)
●Conditions and triggers associated with HF and other major adverse cardiac perioperative events (including death) include myocardial ischemia (eg, ischemia-induced HF), hypertension (poorly controlled or labile), coexistent severe valve dysfunction (stenosis or regurgitation), atrial fibrillation, kidney disease (especially end-stage kidney disease), and diabetes mellitus. A priori knowledge of these triggers of HF may influence clinicians to institute certain interventions early in the perioperative period, such as postoperative dialysis, optimal pain control to avoid hypertension, and the preoperative use of beta blockers or antiarrhythmic medications to prevent postoperative atrial fibrillation. (See 'Preoperative management' below and "Intraoperative management for noncardiac surgery in patients with heart failure", section on 'Hemodynamic management' and 'Postoperative management' below.)
●Risk factors for development of HF include history of alcohol or cocaine abuse, prior myocardial infarction (MI), prior cardiotoxic chemotherapy, longstanding hypertension, family history of HF, and diabetes mellitus. (See "Epidemiology of heart failure".)
Identifying patients at risk for development of HF, such as patients with asymptomatic LV dysfunction, may be difficult. The simplest approach is to have a high index of suspicion when an asymptomatic patient provides a history of risk factors or presents with concerning physical signs (or test abnormalities, as discussed below) (table 2). (See 'Preoperative tests' below.)
Preoperative tests — Routine preoperative testing is generally not indicated. Preoperative tests are selected based upon clinical indications and likelihood of testing changing the decision to proceed with surgery and perioperative management.
Initial tests — Initial tests are performed in patients with HF or suspected HF and in selected patients at risk for HF.
●Electrocardiogram — A preoperative resting 12-lead electrocardiogram (ECG) is suggested in patients with known or suspected cardiovascular disease, including CAD, significant arrhythmia, HF, or LV dysfunction, except for those undergoing low-risk surgery [2]. The ECG may provide diagnostic and prognostic information, and is helpful as a baseline for comparison. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Initial preoperative evaluation'.)
●Chest radiograph — A routine preoperative chest radiograph is not required. However, a chest radiograph is helpful for evaluation of patients with suspected pulmonary edema or other suspected lung disease. (See "Heart failure: Clinical manifestations and diagnosis in adults", section on 'Chest radiograph'.)
●Echocardiogram — Preoperative transthoracic echocardiogram (TTE) is indicated in patients with dyspnea of unknown origin, suspected HF (table 2), HF with changed clinical status (worsening dyspnea), HF without prior TTE, suspected asymptomatic LV dysfunction, or other specific indications for echocardiography, such as suspected valve disease. A rationale for assessing LV function is that LVEF impacts management (as treatment for HF with reduced ejection fraction [HFrEF] differs from treatment for HF with preserved ejection fraction [HFpEF]) and lower LVEF is associated with higher risk of adverse outcomes in patients undergoing noncardiac surgery. (See 'Effect of LVEF' below.)
The above recommendation is consistent with major society guidelines [2,3]. The European Society of Cardiology guideline notes that a TTE should be considered in most high-risk surgical populations, but routine TTE is not indicated in every cardiac patient [3].
●Natriuretic peptide level - While we do not recommend routine measurement of natriuretic peptide (such as B-type natriuretic peptide [BNP] or N-terminal pro-BNP [NT-proBNP]) levels prior to noncardiac surgery, measurement of BNP or NT-proBNP is helpful in patients with suspected HF when the diagnosis is uncertain and may also be helpful in patients with HF when disease severity or stability is uncertain [2]. In this setting, BNP or NT-proBNP levels may help identify patients at increased risk for adverse outcomes [14]. During treatment with sacubitril-valsartan, plasma NT-proBNP levels (but not plasma BNP levels) can be used to assess HF. (See "Heart failure: Clinical manifestations and diagnosis in adults" and "Natriuretic peptide measurement in heart failure".)
The role of natriuretic peptide testing in assessing atherosclerotic cardiovascular risk prior to noncardiac surgery is discussed separately. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Preoperative BNP'.)
Other tests — Additional tests are performed only in patients with standard indications for these tests.
●Exercise test - The patient’s functional status is generally assessed by history (table 3 and table 1), and a preoperative exercise test is not routinely required [2]. Preoperative stress testing is performed if a standard indication for stress testing is present. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Stress testing'.)
●Right heart catheterization or coronary angiography - Routine right heart catheterization or coronary angiography is not indicated prior to noncardiac surgery [2]. Right heart catheterization and/or coronary angiography are performed in selected patients who have standard indications for these procedures. (See "Intraoperative management for noncardiac surgery in patients with heart failure", section on 'Monitoring' and "Non-ST-elevation acute coronary syndromes: Revascularization" and "Chronic coronary syndrome: Overview of care", section on 'Identifying patients for angiography and revascularization' and "Pulmonary artery catheterization: Indications, contraindications, and complications in adults", section on 'Indications'.)
Assessing risk — When assessing the risk of noncardiac surgery, it is important to consider patient- and procedure-related risk factors.
Risk models — Risk stratification of HF patients remains a clinical challenge because no model exhibits consistent discrimination between those patients who will experience an adverse outcome versus those who do not or reliably calibrates the likelihood of outcomes across all levels of risk.
We favor using one of the models for preoperative risk assessment that include HF as well as procedural risk as risk factors, such as the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and/or the Revised Cardiac Risk Index (RCRI) (table 4) [15]. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Risk assessment'.)
●Both the NSQIP and RCRI models include comorbidities such as diabetes mellitus as risk factors, with the NSQIP calculator including a more extensive list of risk factors. However, neither model includes some common established risk factors, such as atrial fibrillation. (See "Atrial fibrillation in patients undergoing noncardiac surgery", section on 'Epidemiology'.)
●Both of these models provide estimates of the risk of cardiac complications; the NSQIP calculator also provides estimates of several other adverse outcomes. The NSQIP definition of cardiac complications includes cardiac arrest and symptomatic MI. The RCRI provides estimates for two definitions of cardiac complications: one definition includes cardiac death, nonfatal MI, and nonfatal cardiac arrest, and the other definition includes MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Risk assessment'.)
The utility of a risk score based on data from a population limited to patients with HF has not been established. A simple risk score for patients with HF undergoing noncardiac surgery was developed using Danish registry data on 16,827 patients [16]. The risk score includes variables from the revised cardiac risk score (except ischemic heart disease) combined with age, sex, body mass index, and presence of emergent surgery. The model was able to discriminate patients with 30-day postoperative mortality risks ranging from <2 to >50 percent. Further study is required to validate this risk score in external cohorts.
Patient-related risk factors — One of the limitations of the available risk models is that history of HF or recent HF is included as a binary risk factor (present or absent), although operative risk varies depending upon the HF syndrome [17], LVEF, right ventricular function, and associated conditions such as pulmonary hypertension and valve dysfunction. (See 'Clinical evaluation' above.)
Risk classification by heart failure syndrome — The stage and severity of HF should also be considered when assessing perioperative risk. The clinical syndromes listed are ranked from the lowest to highest risk for postoperative 30-day major cardiovascular events, 90-day mortality, and long-term cardiovascular mortality (figure 1) [11,17]. (See "Determining the etiology and severity of heart failure or cardiomyopathy".)
●Asymptomatic left ventricular dysfunction - Although limited data are available about the overall perioperative risk of asymptomatic patients with structural heart disease, some data support the notion that this population is prone to adverse outcomes in the setting of intermediate- or high-risk surgery [17].
A study from the Netherlands of patients undergoing high-risk surgery (open vascular procedures) suggested a possible role for identifying patients with asymptomatic LV systolic or diastolic dysfunction [17]. In this study, patients with asymptomatic LV diastolic or systolic function were at increased risk for 30-day major adverse cardiovascular events (MACE) and long-term mortality. Among patients undergoing open vascular surgery, the 30-day cardiovascular event rate was 14 percent among patients with normal LV function as compared with 23 percent among patients with asymptomatic isolated LV diastolic dysfunction, 31 percent among patients with asymptomatic LV systolic dysfunction, and 54 percent among patients with symptomatic HF. For lower-risk procedures (endovascular repair), only symptomatic HF was associated with significantly increased 30-day MACE and long-term cardiovascular mortality.
●Asymptomatic heart failure - Increased postoperative risk is present even among patients with prior symptoms of HF who are asymptomatic immediately preoperatively [11]. In a retrospective cohort study of adult patients receiving elective, noncardiac surgery in a Veterans Affairs database (47,997 with HF and 561,738 without HF), asymptomatic patients with HF (ie, patients with only prior symptoms of HF) experienced increased risk of 90-day postoperative mortality compared with patients without HF (crude mortality risk 4.84 versus 1.22 percent; adjusted absolute risk difference 0.66 percent; adjusted odds ratio [OR] 1.46, 95% CI 1.35-1.57) [11].
●Symptomatic heart failure - Patients with symptomatic HF, particularly those with acute decompensation, are at greater risk for adverse postoperative outcomes compared with patients with only prior HF symptoms. In the above cited Veterans Affairs database study, the 90-day postoperative mortality rates were significantly higher than in patients with prior HF symptoms or no HF (crude mortality rate 10.11 versus 4.84 percent in those with only prior HF symptoms and 1.22 percent with no prior HF; adjusted OR [compared with patients without HF] 2.37, 95% CI 2.14-2.63) [11].
●Newly diagnosed heart failure - Patients with newly diagnosed HF, especially HFrEF (LVEF <40 percent), are at much higher risk than patients with preexisting HF [18]. In patients with HFrEF, the impact of medical therapy on LV function and remodeling is generally only realized after three months of treatment [19].
●Advanced heart failure - Clinical features such as persistent tachycardia, hypotension, hyponatremia, intolerance to an angiotensin converting enzyme inhibitor, worsening renal failure, history of multiple implantable cardioverter-defibrillator shocks, progressive weight loss, and multiple recent hospitalizations are strong predictors of poor short-term survival in patients with established HFrEF [20]. These clinical features should influence the decision on the appropriateness and timing of noncardiac surgery. (See "Management of refractory heart failure with reduced ejection fraction".)
Effect of LVEF — Among patients with HF undergoing noncardiac surgery, the risk of adverse postoperative outcomes is higher with lower LVEF [11,21]. This relationship was illustrated by the above cited Veterans Affairs database study, in which the 90-day postoperative mortality rate among patients with HF was lowest among patients with HFpEF (4.88 percent), similar in patients with HFmrEF (5.11 percent), higher in patients with LVEF 30 to 39 percent (6.58 percent), and highest in patients with LVEF <30 percent (8.34 percent); the adjusted ORs (95% CI) compared with no HF were 1.51 (1.40-1.62), 1.53 (1.38-1.71), 1.85 (1.68-2.05), and 2.35 (2.09-2.63), respectively [11].
As discussed separately, data are conflicting as to whether the general prognosis for hospitalized patients with HF differs with HFpEF and HFrEF. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Prognosis'.)
Effect of right ventricular function — There is growing evidence that preoperative reduced right ventricular function, as measured by echocardiography, is associated with increased rates of perioperative adverse cardiac events. Hence, right ventricular dysfunction in the moderate to severe range is likely to impact postoperative outcomes, independent of LVEF [22,23].
Procedural risk factors — Surgical procedural factors that influence cardiac risk are related to the temporal necessity of a procedure, invasiveness, type, and duration of the operation, as well as the change in body core temperature, blood loss, and fluid shifts [24]. The risk models suggested above include procedural risk at differing levels of detail. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator includes procedure-specific risk along with detailed clinical risk factors. The Revised Cardiac Risk Index (RCRI) (table 4) is a simpler approach that incorporates high-risk surgery as a risk-factor.
●By type of procedure – Surgical interventions can be broadly divided into low-, intermediate-, and high-risk procedures (table 5), with estimated 30-day cardiac event rates (cardiac death and MI) of 1, 1 to 5, and 5 percent, respectively [24].
●By temporal necessity – The temporal necessity of an operation determines the amount of time available for preoperative assessment and management. The 2014 perioperative guidelines included the following definitions [2]:
•Emergency surgery is generally performed within six hours when life or limb is threatened (risk of mortality or significant morbidity) and there is no or very limited time for preoperative clinical evaluation and preoperative management (eg, ruptured abdominal aortic aneurysm or hemicolectomy for life-threatening gastrointestinal bleeding).
•An urgent procedure is one in which life or limb is threatened (risk of mortality or significant morbidity) if not in the operating room within 6 to 24 hours (eg, hemicolectomy for perforated large bowel). There is generally only limited time for preoperative evaluation and management.
An additional term not included in the guidelines is a "semi-urgent procedure," which is one performed within a few days (eg, patients with progressive bowel obstruction).
•A time-sensitive procedure is one which is performed within one to six weeks to avoid negative impact on outcome (eg, oncologic procedures).
•An elective procedure is one in which the procedure could be delayed for up to one year (eg, knee replacement).
Patients who require emergency or urgent surgery are at increased risk of a perioperative cardiovascular event at any level of baseline risk. For these patients, risk indices derived from studies of patients undergoing elective surgery are not accurate, though they may provide an estimate of the lower bounds of risk. (See "Management of cardiac risk for noncardiac surgery".)
DECIDING WHETHER TO PROCEED WITH SURGERY — Decision-making for patients with HF with indications for noncardiac surgery is categorized according to the temporal necessity of surgery (emergency, urgent, or elective), the clinical HF syndrome, and the estimated perioperative risk. Decision-making in this setting involves a multidisciplinary team approach (typically including primary care clinician, cardiologist, surgeon, and anesthesiologist) (see "Intraoperative management for noncardiac surgery in patients with heart failure"). Once a patient with known heart disease has been thoroughly evaluated and an assessment of risk has been performed, the health care providers caring for the patient need to collectively decide on one of three options:
●Proceed with surgery without any additional testing or new medical interventions prior to surgery
●Postpone surgery and proceed with surgery only after HF has been stabilized
●Reconsider the need for surgery or explore alternative procedures and therapies
Emergency surgery — For patients with an indication for emergency surgery, options for preoperative clinical assessment and management are limited. Since emergency surgery must generally be performed within six hours to save life or limb (avoid mortality or significant morbidity), clinical risk assessment is closely followed by decision-making with the patient and patient’s family regarding whether to proceed with surgery or palliation. Patients with altered hemodynamics (including those with new or decompensated HF) that cannot be corrected before surgery may benefit from invasive hemodynamic monitoring [2]. (See "Intraoperative management for noncardiac surgery in patients with heart failure", section on 'Monitoring'.)
When patients with symptomatic HF require emergency (or urgent) high-risk surgery, we suggest that physicians who are proficient in the care of advanced HF be involved in the management of these patients perioperatively. In this setting, there is limited time for patient evaluation, and skilled interpretation of available information is needed to optimize perioperative management.
Urgent or elective surgery — For patients with an indication for urgent or elective surgery, more time is available for preoperative risk assessment and management (algorithm 1A-B). These decisions can be categorized in terms of the temporal necessity of surgery (urgent or elective), clinical HF syndrome, and the estimated risk associated with the intervention.
Examples of decision tree pathways:
●Proceed with surgery without additional testing or intervention. Clinical scenarios include:
•Patients with stable HF syndromes (including patients at risk for HF and patients with stable HF) requiring elective or urgent surgery with perioperative risk of major adverse cardiac events (MACE) <1 percent.
•Patients with stable HF syndromes with good functional capacity requiring elective or urgency surgery with perioperative risk of MACE >1 percent.
•Patients with stable HF syndromes with limited functional capacity requiring urgent surgery with perioperative risk of MACE >1 percent, for whom the risk-to-benefit analysis favors proceeding with the intervention.
•Patients with decompensated HF or new-onset HFrEF with limited time for stabilization for whom the risk-to-benefit analysis favors urgent surgery. These patients may benefit from intraoperative hemodynamic monitoring as well as management by physicians proficient in the care of advanced HF. (See "Intraoperative management for noncardiac surgery in patients with heart failure", section on 'Monitoring'.)
●Proceed with surgery once HF has been stabilized. Clinical scenarios include:
•For a patient with newly diagnosed HFrEF who is scheduled for elective surgery, postpone surgery for at least three months to allow medical stabilization [3]. This approach provides an opportunity for optimizing treatment of these patients and may allow time for improvement in LV function.
•For patients with decompensated HFrEF or new or decompensated HFpEF, delay elective surgery for at least one month to allow adequate optimization of therapy and stabilization of clinical status.
•For patients with decompensated HF or new onset HF who require semi-urgent surgery, delay surgery for a couple of days to allow optimization and stabilization of clinical status.
•For patients with uncertain stability and severity of HF, postpone elective surgery as needed until status is clarified and stabilized. This would allow for additional testing and management prior to surgery.
●Reconsider surgery or explore alternatives in clinical settings in which the estimated risks of surgery outweigh the benefits. This includes settings in which the perioperative risk is prohibitive and/or the likely benefit from surgery is uncertain, as may arise particularly in patients with advanced or end-stage HF. It is worth noting that most physicians tend to overestimate survival in advanced chronic medical conditions, especially when patients have to deal with two to three comorbid conditions [25,26]. (See "Overview of comprehensive patient assessment in palliative care", section on 'Illness understanding and care preferences' and "Palliative care for patients with advanced heart failure: Indications and systems of care", section on 'Disease course and prognosis'.)
PREOPERATIVE MANAGEMENT
In general, patients with a history of HF who are asymptomatic at the time of surgery should continue their current medical regimen. Patients with symptomatic HF prior to surgery should receive medical therapy to optimize their clinical status. There is little evidence on how to manage HF in the preoperative period. Given the paucity of evidence, one should take a similar approach to that used for the general management of HF [1]. (See "Treatment of acute decompensated heart failure: Specific therapies" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
The goals of optimization to achieve stability in patients with preoperative HF are similar to those of all patients with decompensated HF (see "Treatment of acute decompensated heart failure: General considerations"):
●Improve symptoms, especially congestion and low-output symptoms
●Restore normal oxygenation
●Optimize volume status and improve end-organ perfusion
●Identify etiology
●Identify and address precipitating factors
The timing of surgery once HF is stabilized is generally dictated by the clinical response to treatment and the urgency of surgery.
While routine pulmonary artery catheter (PAC) monitoring is not recommended for patients with HF, perioperative PAC use may be helpful to guide management in selected patients, including those with acute decompensated HF that cannot be stabilized prior to urgent surgery. (See "Intraoperative management for noncardiac surgery in patients with heart failure", section on 'Pulmonary artery catheter'.)
Medication management — For patients with chronic HF on evidence-based long-term therapy for HF, this therapy is generally continued preoperatively. For patients with HF who have not previously received these long-term medications, initiation of certain agents (eg, beta blockers) is generally delayed to avoid the potential risk of perioperative adverse effects.
General recommendations regarding the perioperative management of medications are reviewed separately. (See "Perioperative medication management".)
●ACE inhibitor, ARNI, or ARB – For patients with chronic HFrEF, treatment with an angiotensin converting enzyme (ACE) inhibitor, angiotensin receptor-neprilysin inhibitor (ARNI), or single-agent angiotensin II receptor blocker (ARB) is a cornerstone of therapy (see "Initial pharmacologic therapy of heart failure with reduced ejection fraction in adults"), and such treatment is commonly continued in the perioperative period. However, since established benefits are from chronic use, brief temporary discontinuation is acceptable when there is risk of excessive hypotension (eg, related to intravascular volume depletion or medications such as anesthetics). In an effort to reduce the risk of intraoperative hypotension, one potential option is to give the last preoperative dose of ACE inhibitor or ARB on the evening prior to the day of surgery (and not on the morning of surgery) [3] or to withhold the drug on the day of surgery.
Evidence for an association between preoperative withholding of ACE inhibitor or ARB (taken for various indications) and reduced risk of intraoperative hypotension is discussed separately; the applicability of this observation to patients with HF is uncertain. (See "Perioperative medication management", section on 'ACE inhibitors and angiotensin II receptor blockers'.)
For patients with newly diagnosed HFrEF preoperatively, an ACE inhibitor, ARNI, or ARB is generally a key first-line therapy. However, delayed initiation of such therapy (or reduction or discontinuation of ongoing therapy) is appropriate in patients with HF when acute hypotension is a concern. (See "Treatment of acute decompensated heart failure: General considerations" and "Use of diuretics in patients with heart failure".)
●Beta blocker – Long-term outcomes in patients with HFrEF are improved with beta blocker therapy. Patients who are already receiving and tolerating beta blockers (including patients with HF) should generally continue such therapy perioperatively [2,3]. (See "Initial pharmacologic therapy of heart failure with reduced ejection fraction in adults".)
For patients with chronic HFrEF who have not been receiving a beta blocker, initiation of beta blockade immediately preoperatively should generally be avoided given risk of harm (including stroke and death). Since the beneficial effects of beta blockade can take weeks or months, beta blockade should not be initiated in the preoperative period in patients with LV systolic dysfunction unless surgery can be substantially delayed (eg, at least two to four weeks). Rapid preoperative titration of beta blockade would not be expected to be beneficial and may cause harm. (See "Management of cardiac risk for noncardiac surgery", section on 'Beta blockers'.)
For patients with acute decompensated HF preoperatively, initiation of beta blocker therapy is generally deferred. (See "Treatment of acute decompensated heart failure: General considerations".)
●Mineralocorticoid receptor antagonist – For patients with chronic HFrEF or HFpEF with stable renal function who are receiving and tolerating mineralocorticoid receptor antagonist (without hyperkalemia), it is reasonable to continue such therapy preoperatively and to resume therapy early postoperatively if renal function continues to be stable and there are no other risk factors for hyperkalemia.
For patients with newly diagnosed HFrEF or HFpEF, we defer initiation of mineralocorticoid receptor antagonist until after the immediate perioperative period. Long-term mineralocorticoid receptor antagonist (spironolactone or eplerenone) therapy is beneficial in selected patients with HFrEF and may be beneficial for selected patients with HFpEF. However, there is no evidence that a mineralocorticoid receptor antagonist is useful in the perioperative period. (See "Secondary pharmacologic therapy in heart failure with reduced ejection fraction (HFrEF) in adults", section on 'Mineralocorticoid receptor antagonist' and "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Mineralocorticoid receptor antagonists'.)
●Digoxin – For patients who are already receiving digoxin as a component of chronic therapy for HFrEF, this medication is generally continued perioperatively. Loading doses of digoxin (as may be used for rate control in patients with atrial fibrillation) are not indicated in patients with HF. Digoxin is not an agent for stabilization of patients with an acute exacerbation of HF. (See "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Specific therapies".)
The management of perioperative atrial fibrillation with rate control agents (such as beta blockers, calcium channel blockers, and digoxin) is discussed separately. (See "The management of atrial fibrillation in patients with heart failure", section on 'Acute decompensation' and "Atrial fibrillation in patients undergoing noncardiac surgery".)
●Diuretics – Diuretics are used as needed to manage perioperative volume overload [27]. Potential issues for patients receiving diuretic therapy are continued volume overload (inadequate diuresis), hypovolemia (overdiuresis) and electrolyte disorders (such as hypokalemia caused by loop diuretic therapy without adequate potassium repletion). (See "Use of diuretics in patients with heart failure".)
Management of cardiac implantable electronic devices — Perioperative management of pacemakers and implantable cardioverter-defibrillators is discussed separately. (See "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator".)
INTRAOPERATIVE MANAGEMENT — Intraoperative management of HF in patients undergoing noncardiac surgery is discussed separately. (See "Intraoperative management for noncardiac surgery in patients with heart failure".)
POSTOPERATIVE MANAGEMENT — Patients with HF require close postoperative monitoring and management given their increased risk of cardiovascular complications, including death. (See 'Epidemiology' above and 'Assessing risk' above.)
Monitoring and evaluation — Postoperative monitoring should include assessment of volume status, hemodynamic stability, and respiratory status, including evaluation for symptoms and signs of acute HF. (See 'Acute heart failure' below.)
Clinicians should closely monitor the volume status by reviewing the records of fluid infusion and output during the operative and immediate postoperative period. Excessive fluid administration is a common cause of postoperative pulmonary edema. One series of 13 fatal cases of postoperative pulmonary edema found fluid administration of at least 67 mL/kg (approximately 5 L for a 70 kg individual) in the initial 24 postoperative hours [28]. Twelve of the 13 patients had no known prior cardiac disease, and in eight of the patients, cardiopulmonary arrest was the first sign of pulmonary edema. The amount of fluid administration in a control group of patients was not presented.
Acute heart failure
Diagnosis — Acute HF typically manifests as respiratory distress with or without pulmonary edema and may be associated with hypertension or hypotension. Patients with acute HF should be evaluated for MI or ischemia including electrocardiography, cardiac monitoring, and serial troponin measurements. This assessment can be challenging since postoperative MI often presents atypically and may have etiologies different from MI occurring in other settings. (See "Approach to diagnosis and evaluation of acute decompensated heart failure in adults" and "Perioperative myocardial infarction or injury after noncardiac surgery" and "Cardiovascular problems in the post-anesthesia care unit (PACU)", section on 'Postoperative cardiovascular complications'.)
Differential diagnosis — Postoperative shortness of breath can have many etiologies other than acute HF (table 6). The general assessment of postoperative patients is discussed separately. (See "Overview of the management of postoperative pulmonary complications".)
In addition, postoperative pulmonary edema can have etiologies other than HF. Pulmonary edema resulting from postanesthesia laryngospasm has been described, often in young adults who are otherwise healthy and undergoing only minor operative procedures [29-32]. This syndrome, sometimes called "negative pressure pulmonary edema," is poorly understood and often not recognized. It may occur in as many as 0.1 percent of all anesthesia cases [33]. The prognosis for complete recovery in these patients is excellent [33,34]. Other causes of postoperative pulmonary edema include lateral decubitus positioning during surgery [35], pneumonectomy [36-38], lung transplantation [39], cocaine use [40,41], or, rarely, pheochromocytoma [42]. (See "Overview of the management of postoperative pulmonary complications".)
Management of acute heart failure — Postoperative acute HF is treated as in other clinical settings. Diuretics are generally administered acutely as needed and vasodilator therapy is added in patients without hypotension as indicated. (See "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Specific therapies".)
Postoperative MI or ischemia is a common etiology of HF and presents some management difficulties in the postoperative period, as discussed separately; these patients are ideally managed by physicians experienced in perioperative cardiac care. (See "Perioperative myocardial infarction or injury after noncardiac surgery" and "Treatment of acute decompensated heart failure in acute coronary syndromes".)
The management of acute decompensated HF in the post-anesthesia care unit (PACU) setting is discussed further separately (table 7). (See "Cardiovascular problems in the post-anesthesia care unit (PACU)", section on 'Decompensated heart failure'.)
Institution of long-term therapy — Evidence-based long-term therapy for HF is generally initiated or reinstated postoperatively as soon as the patient is hemodynamically stable. The approach to initiation of medications is similar to that followed for patients hospitalized with acute HF. (See "Treatment of acute decompensated heart failure: Specific therapies", section on 'Approach to long-term therapy in hospitalized patients'.)
Specifically, for patients with HFrEF, treatment with an angiotensin converting enzyme (ACE) inhibitor, angiotensin receptor-neprilysin inhibitor (ARNI), or single-agent angiotensin II receptor blocker (ARB) should be resumed early in the postoperative period, as tolerated. In observational studies not limited to patients with HF, failure to restart an ACE inhibitor or ARB within 48 hours [43] or two weeks [44] after surgery was associated with increased 30-day mortality rate in risk-adjusted analyses, although residual confounding cannot be excluded. (See "Perioperative medication management", section on 'ACE inhibitors and angiotensin II receptor blockers' and "Management of cardiac risk for noncardiac surgery", section on 'ACE inhibitor or ARB'.)
Patients who develop HF postoperatively have a significantly increased risk of hospital readmission, confirming the need for careful discharge planning and close follow-up, ideally using a multidisciplinary approach [3]. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Heart failure in adults" and "Society guideline links: Perioperative cardiovascular evaluation and management".)
SUMMARY AND RECOMMENDATIONS
●Heart failure (HF) is a major risk factor for adverse cardiac events, including death following noncardiac surgery. Data suggest that patients with chronic HF are at higher risk for major adverse cardiac events following noncardiac surgery than patients with coronary artery disease. (See 'Epidemiology' above.)
●Evaluation of patients prior to noncardiac surgery should include the following (see 'Preoperative evaluation' above):
•Identifying patients with known or suspected HF or at risk of developing perioperative HF. For patients with suspected HF, performing a diagnostic evaluation to determine whether HF or another condition is present. (See "Heart failure: Clinical manifestations and diagnosis in adults".) (Related Pathway(s): Heart failure: Diagnosis and classification.)
•For patients with HF:
-Determining whether patients with HF are stable and optimally managed or decompensated. (See 'Clinical evaluation' above and 'Preoperative tests' above and "Determining the etiology and severity of heart failure or cardiomyopathy" and "Approach to diagnosis and evaluation of acute decompensated heart failure in adults".)
-Recognizing high-risk HF syndromes, including acute HF (new onset or decompensated), advanced HF, and HF with very low left ventricular ejection fraction (LVEF <30 percent). (See "Approach to diagnosis and evaluation of acute decompensated heart failure in adults" and "Clinical manifestations and diagnosis of advanced heart failure".)
-Identifying comorbidities that may impact the stability of HF in the postoperative period. (See 'Assessing risk' above.)
●Routine preoperative testing is generally not indicated. Preoperative tests are selected based upon clinical indications and likelihood of testing changing the decision to proceed with surgery and perioperative management. Preoperative transthoracic echocardiogram (TTE) is indicated in patients with dyspnea of unknown origin, suspected HF (table 2), HF with changed clinical status (worsening dyspnea), HF without prior TTE, suspected asymptomatic LV dysfunction or other specific indications for echocardiography, such as suspected valve disease. (See 'Preoperative tests' above.)
●Risk stratification of HF patients remains a clinical challenge because no model exhibits consistent discrimination between those patients who will experience an adverse outcome versus those who do not. We favor using one of the models for preoperative risk assessment that include HF as well as procedural risk as risk factors, such as the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and/or the Revised Cardiac Risk Index (RCRI) (table 4) [15]. A limitation of the available risk models is that HF is included as a binary risk factor (present or absent), although operative risk varies depending upon HF syndrome (figure 1), LVEF, right ventricular function, and associated conditions such as pulmonary hypertension and valve dysfunction. (See 'Assessing risk' above and "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Risk assessment'.)
●Decision making for patients with HF with indications for noncardiac surgery is categorized according to the temporal necessity of surgery (emergency, urgent, or elective), the clinical HF syndrome, and the estimated perioperative risk (algorithm 1A-B). (See 'Deciding whether to proceed with surgery' above.)
●For patients with chronic HF on evidence-based long-term therapy for HF, this therapy is generally continued preoperatively. For patients with HF who have not previously received these long-term medications, initiation of certain agents (eg, beta blockers) is generally delayed to avoid the potential risk of perioperative adverse effects. (See 'Medication management' above.)
●Postoperative monitoring should include assessment of volume status, hemodynamic stability, and respiratory status, including evaluation for symptoms and signs of acute HF. (See 'Acute heart failure' above.)
●Evidence-based long-term therapy for HF is generally initiated or reinstated postoperatively as soon as the patient is hemodynamically stable. (See 'Institution of long-term therapy' above.)
