Recent Acute Decompensated Heart Failure Predicts Postoperative Cardiovascular Events

Abstract

Acute decompensated heart failure (ADHF) is considered a major perioperative risk factor. Vascular surgery, excluding carotid endarterectomy, is a high risk procedure. Current guidelines do not address the optimal timing of elective, vascular surgery following an episode of ADHF. We hypothesized that ADHF occurring within 30 days prior to elective vascular surgery, independently predicts postoperative cardiovascular events. The American College of Surgeons - National Surgical Quality Improvement Program (NSQIP) database is a prospectively validated dataset of a sample of all non-cardiac surgical procedures. All elective vascular surgical patients from our institutional NSQIP from 2006 to 2010 were studied. The primary exposure was a history of ADHF within 30 days prior to surgery. The primary outcome was a composite of death, heart failure, postoperative MI, and ischemic stroke. Concomitant comorbidities, surgical and anesthetic data were evaluated. NSQIP data definitions were used for all data elements except “history of HF”, which was extracted from the electronic medical record using a previously validated search. The primary hypothesis was tested using logistic regression. Of 1291 study patients, 13 (1.0%) had ADHF within 30 days prior to surgery. Patients with ADHF were older, had a greater incidence of diabetes and ESRD (Table 1). Indices of surgical complexity including duration of surgery, and estimated blood loss were similar between the two groups. The primary outcome occurred in 3/13 (23.1%) patients with ADHF compared to 64/1278 (5.0%) patients without (p 0.004). After multivariate adjustment, ADHF was a strong predictor of postoperative cardiovascular events [OR 5.4, 95% CI 1.1 - 22.8] (Table 2). ADHF occurring within 30 days prior to elective vascular surgery is independently associated with increased risk of postoperative cardiovascular events. These data suggest that elective vascular surgery should be delayed for at least 30 days following an episode of ADHF.Table 1Baseline characteristicsVariablesRecent ADHF - NORecent ADHF - YESN1278 (99%)13 (1%)Age (years)∗Mean (SD).66.5 (14.3)75.1 (7.1)Weight (kg)∗Mean (SD).84.0 (20.2)76.5 (17.4)Current smoking334 (26.1%)4 (30.8%)Diabetes216 (16.9%)5 (38.5%)‡Statistically significant.Hypertension894 (70.0%)11 (84.6%)Cerebrovascular disease214 (16.7%)4 (30.8%)ESRD24 (1.9%)2 (15.4%)‡Statistically significant.CAD410 (32.1%)6 (46.2%)Duration of surgery (minutes)∗Mean (SD).247.8 (147.0)175.5 (105.2)Estimated surgical blood loss (ml)∗Mean (SD).884.3 (1510.0)1083.3 (1528.3)∗ Mean (SD).‡ Statistically significant. Open table in a new tab Table 2Adjusted odds ratios for Postoperative Cardiovascular Complications or DeathOR∗- Odds Ratio per unit change. (95% CI)p valueADHF within 30 days prior to surgery5.4 (1.1-22.8)0.04ESRD4.8 (1.6-12.5)0.01Age (per decade)1.6 (1.2-2)<0.01Length of surgery (per 30 minutes)1.1 (1-1.1)<0.01History of Diabetes1.6 (0.8-2.8)0.15History of CVA or TIA1.5 (0.8-2.7)0.16History of HF1.6 (0.7-4.1)0.27History of CAD1.3 (0.8-2.2)0.32Hypertension1.1 (0.6-2.4)0.7Abbreviations: CVA, CerebroVascular Accident; TIA, Transient Ischemic Attack; CAD, Coronary Artery Disease.∗ - Odds Ratio per unit change. Open table in a new tab