Association of Left Ventricular Ejection Fraction and Symptoms With Mortality After Elective Noncardiac Surgery Among Patients With Heart Failure

Importance: Heart failure is an established risk factor for postoperative mortality, but how left ventricular ejection fraction and heart failure symptoms affect surgical outcomes is not fully described. Objectives: To determine the risk of postoperative mortality among patients with heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity compared with those without heart failure and to evaluate how risk varies across levels of surgical complexity. Design, Setting, and Participants: US multisite retrospective cohort study of all adult patients receiving elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database from 2009 through 2016. A total of 609 735 patient records were identified and analyzed with 1 year of follow-up after having surgery (final study follow-up: September 1, 2017). Exposures: Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery. Main Outcome and Measure: The primary outcome was postoperative mortality at 90 days. Results: Outcome data from 47 997 patients with heart failure (7.9%; mean SD age, 68.6 10.1 years; 1391 women 2.9%) and 561 738 patients without heart failure (92.1%; mean SD age, 59.4 13.4 years; 50 862 women 9.1%) were analyzed. Compared with patients without heart failure, those with heart failure had a higher risk of 90-day postoperative mortality (2635 vs 6881 90-day deaths; crude mortality risk, 5.49% vs 1.22%; adjusted absolute risk difference RD, 1.03% 95% CI, 0.91%-1.15%; adjusted odds ratio OR, 1.67 95% CI, 1.57-1.76). Compared with patients without heart failure, symptomatic patients with heart failure (n = 5906) had a higher risk (597 deaths 10.11%; adjusted absolute RD, 2.37% 95% CI, 2.06%-2.57%; adjusted OR, 2.37 95% CI, 2.14-2.63). Asymptomatic patients with heart failure (n = 42 091) (2038 deaths crude risk, 4.84%; adjusted absolute RD, 0.74% 95% CI, 0.63%-0.87%; adjusted OR, 1.53 95% CI, 1.44-1.63), including the subset with preserved left ventricular systolic function (1144 deaths 4.42%; adjusted absolute RD, 0.66% 95% CI, 0.54%-0.79%; adjusted OR, 1.46 95% CI, 1.35-1.57), also experienced elevated risk. Conclusions and Relevance: Among patients undergoing elective noncardiac surgery, heart failure with or without symptoms was significantly associated with 90-day postoperative mortality. These data may be helpful in preoperative discussions with patients with heart failure undergoing noncardiac surgery.