Closing the peri‐operative heart failure gap: insights and imperatives from METREPAIR

I read with interest the article by Kirkopoulos et al. analysing peri-operative outcomes in 15,158 middle-aged and older patients with increased cardiovascular risk, 25.6% of whom met diagnostic criteria for stable chronic heart failure [1]. In this secondary analysis of the multicentre METREPAIR cohort, chronic heart failure was independently associated with a doubling of 30-day major adverse cardiovascular events (adjusted OR 2.04), a 50% increase in 30-day mortality (OR 1.50) and a 47% rise in severe in-hospital complications (OR 1.47). Notably, fewer than one-third of patients with heart failure underwent pre-operative transthoracic echocardiography, yet those with a left ventricular ejection fraction < 40% experienced still higher cardiovascular risk (OR 2.0). These findings underscore the persistent vulnerability of patients with heart failure undergoing non-cardiac surgery and spotlight potential gaps in pre-operative cardiac evaluation and optimisation. Although guidelines endorse natriuretic-peptide screening and focused transthoracic echocardiography for patients with known or suspected heart failure [2], fewer than one-third of the cohort received imaging, missing an opportunity to optimise disease-modifying therapy, arrange iron repletion or schedule elective revascularisation. Postoperative high dependency or intensive care monitoring was documented in only 55% of cases, even though haemodynamic perturbations during the first 24 h account for most adverse cardiac events [3]. Peri-operative continuation of β-blockers, renin-angiotensin-aldosterone inhibitors and sodium-glucose co-transporter-2 inhibitors, therapies with clear benefit in reducing mortality, was not reported, raising concerns about adherence to contemporary heart failure pathways. These gaps underline the need for structured, multidisciplinary protocols that couple pre-operative optimisation with proactive postoperative surveillance in this high-risk population. Implementing a structured peri-operative heart failure pathway could mitigate these gaps. Routine measurement of NT-proBNP (cut-off ≥ 300 pg.ml-1) or confirmation of a recent transthoracic echocardiogram to triage patients to cardiology-led optimisation clinics is advocated by the American College of Cardiology and the American Heart Association and is supported by cohort data showing a two-fold rise in 30-day morbidity above this biomarker threshold [4]. Patients with elevated natriuretic peptides or left ventricular ejection fraction < 40% should have elective surgery deferred until guideline-directed medical therapy, intravenous iron and, when appropriate, coronary or valvular intervention instigated, as shown in specialised heart failure surgical programmes [5]. High-dependency or intensive care for the first 24 h – combined with continuous telemetry and haemodynamic index-guided fluid management – facilitates early detection of arrhythmia or low-output states, while electronic medication reconciliation safeguards peri-operative continuation of cardioprotective drugs. Capturing these elements in a prospective registry would permit benchmarking against the METREPAIR dataset and inform future randomised implementation studies. Kirkopoulos et al. should be commended for quantifying the peri-operative vulnerability of patients with chronic heart failure and invite a multinational collaboration – linking anaesthesia, cardiology, surgery and data-science teams – to test biomarker-guided triage prospectively, fast-track optimisation clinics and mandatory postoperative high-dependency admission for this cohort. Establishing such a registry would allow contemporary pathways to be benchmarked against METREPAIR outcomes and accelerate consensus on best practices that translate into measurable reductions in morbidity and mortality.