Incidence, Determinants and Mortality of Heart Failure Associated With Medical-Surgical Procedures in Patients ≥ 65 Years of Age (from the Cardiovascular Health Study)

https://doi.org/10.1016/j.amjcard.2021.05.017Get rights and content

Heart failure (HF) and myocardial infarction are serious complications of major noncardiac surgery in older adults. Many factors can contribute to the development of HF during the postoperative period. The incidence of, and risk factors for, procedure-associated heart failure (PHF) occurring at the time of, or shortly after, medical procedures in a population-based sample ≥ 65 years of age have not been fully characterized, particularly in comparison with HF not proximate to medical procedures. This analysis comprises 5,121 men and women free of HF at baseline from the Cardiovascular Health Study who were followed up for 12.0 years (median). HF events were documented by self-report at semi-annual contacts and confirmed by a formal adjudication committee using a review of the participants’ medical records and standardized criteria for HF. Incident HF events were additionally adjudicated as either being related or unrelated to a medical procedure (PHF and non-PHF, respectively). We estimated cause-specific hazards ratios for the association of covariates with PHF and non-PHF. There were 1,728 incident HF events in the primary analysis: 168 (10%) classified as PHF, 1,526 (88%) as non-PHF, and 34 unclassified (2%). For those 1,045 participants in whom LV ejection fraction was known at the time of the HF event, it was ≥45% in 89 of 118 participants (75%) with PHF, compared to 517 of 927 participants (55%) with non-PHF (p < 0.001). Increased age, male gender, diabetes, and angina at baseline were associated with both PHF and non-PHF (range of hazard ratios (HR): 1.04–2.05]. Being Black was inversely associated with PHF [HR: 0.46, 95% confidence interval: 0.25–0.86]. Participants with increased age, without baseline angina, and with baseline LVEF<55% were at a significantly lower risk for PHF compared to non-PHF. Among those with PHF, surgical procedures—including cardiac, orthopedic, gastrointestinal, vascular, and urologic—comprised 83.3%, while percutaneous procedures comprised 8.9% (including 6.5% represented by cardiac catheterizations and pacemaker placements). Another group composed of a variety of procedures commonly requiring large fluid volume administration comprised 7.7%. There was a lower all-cause 30-day mortality in the PHF versus the non-PHF group (2.2% vs 5.7%), with a nonsignificant odds ratio of 0.39 in a minimally adjusted model. When individuals with prior myocardial infarction (MI) were excluded in a sensitivity analysis, the proportion of incident HF with concurrent MI was greater for PHF (32.9%) than for non-PHF (19.8%). In conclusion, PHF in older adults is a common entity with relatively low 30-day mortality. Baseline angina, lower age, and LVEF ≥ 55% were associated with a higher risk of PHF compared to non-PHF. Being Black was associated with a lower risk of PHF and PHF as a proportion of HF was lower in Black than in non-Black participants. Compared to non-PHF, PHF more frequently presented with concurrent MI and with preserved LV ejection fraction.

Section snippets

Methods

CHS is a population-based, observational longitudinal study of risk factors for cardiovascular disease in adults 65 years or older. The methods of the Cardiovascular Health Study (CHS) have been previously described.10, 11, 12 The study enrolled an original cohort of 5,201 participants from 1989 to 1990 and an additional predominantly Black cohort of 687 participants from 1992 to 1993, resulting in a total of 5,888 participants. Participants were enrolled from Forsyth County, North Carolina;

Results

There were 5,888 participants in CHS and 1,904 cases of incident HF, of which 182 were classified as PHF, 1,682 as non-PHF and 40 could not be classified as to whether or not HF was procedural. There were 5,121 participants in the primary analysis after excluding 275 with HF at baseline and 492 with missing risk factors. Of the 5,121, 1,728 (34%) developed new HF during a median follow-up of 12.0 years (interquartile range: 6.8–18.2 years). Of these, 168 (10%) were classified as PHF, 1,526

Discussion

The principal findings of this study are that in free-living individuals ≥ 65 years of age, PHF is not uncommon—occurring in approximately 3% of our cohort overall and 10% of incident HF cases over a 12-year (median) follow-up period. Our aim was to determine the burden of PHF in a community-dwelling cohort followed prospectively, the baseline risk factors associated with this outcome versus first-ever HF not associated with procedures, and the 30-day mortality for PHF versus non-PHF. To our

Credit Author Statement

Monali Shah, DO, was involved in preparation of initial drafts of the final manuscript. Carlos J. Rodriguez MD, MPH, was involved in data collection, analysis and preparation, and editing drafts of the manuscript. Traci M. Bartz MS was involved in statistical analysis and in preparation, critical review, and editing drafts of the manuscript. Mary F. Lyles MD was involved in project conceptualization, data collection and preparation, and editing drafts of the manuscript. Jorge R. Kizer MD, MS,

Funding sources

This research was supported by contracts HHSN268201200036C, HHSN268200800007C, HHSN268201800001C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, and grants U01HL080295 and U01HL130114 from the National Heart, Lung, and Blood Institute (NHLBI), with additional contribution from the National Institute of Neurological Disorders and Stroke (NINDS). Additional support was provided by R01AG023629 from the National Institute on Aging (NIA). A full list of principal

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Carlos Jose Rodriguez reports a relationship with Amgen, Inc. that includes funding grants. Carlos Jose Rodriguez reports a relationship with National Institutes of Health that includes funding grants. Carlos Jose Rodriguez reports a relationship with American Heart Association that includes funding grants. Jorge Kizer reports

References (26)

  • ME Charlson et al.

    Risk for postoperative congestive heart failure

    Surg Gynecol Obstet

    (1991)
  • PJ Devereaux et al.

    Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial

    The Lancet

    (2008)
  • L. Goldman

    Cardiac risks and complications of noncardiac surgery

    Ann Intern Med

    (1983)
  • Cited by (0)

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    MS and CJR contributed equally as first authors.

    JMG and JSG contributed equally as senior authors.

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