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Non-cardiac surgery in the heart failure patient

In this era of increasingly procedural cardiology, many physicians regard the cognitive exercise of preoperative evaluation for non-cardiac surgery as an onerous task. In reality, the preoperative period affords a window of opportunity for the consulting cardiologist to minimise surgical risk by maximising medical treatment, directing appropriate testing, and communicating effectively with the surgical team. Many physicians are unaware that nearly half of all perioperative deaths are related to cardiac events, and they may greatly underestimate the degree to which heart failure contributes to this cardiac mortality. It is imperative as a consulting cardiologist to develop a consistent approach to heart failure patients in order to avoid unnecessary, and potentially dangerous, preoperative diagnostic and therapeutic interventions.

In this article we will briefly review recent data relating to predictors of surgical risks, and propose an approach for integrating the clinical evaluation of cardiac status and surgical risk in order to provide a frame of reference for preoperative consultation. We have no hard evidence, either observational or in the form of prospective, randomised trials, to support many of our current recommendations. The landmark studies of preoperative risk assessment focused primarily on identifying ischemic risk with a lesser emphasis on heart failure.1 2 Our suggestions are based on heart failure data extrapolated from these studies, as well as from broad experience at a high volume cardiac centre.

There are four major determinants of risk for any cardiac patient undergoing non-cardiac surgery: urgency of the surgery; complexity of the procedure; extent of medical comorbidities; and the extent and severity of the underlying heart disease. Shah and associates underscored the importance of these variables in their evaluation …