Acute heart failure in non-cardiac surgery

Abstract

More than 64 million people worldwide have heart failure (HF), and these numbers are expected to rise. Acute HF (AHF) is the leading cause of hospitalization in patients over 65 years old and is linked to high mortality and readmission rates. AHF may also be a frequent complication in patients hospitalized for other medical reasons as well as after cardiac or non-cardiac surgery. These three entities are summarized as secondary AHF. As secondary AHF has been largely overlooked by medical research and education, little is known about its pathophysiology, phenotypes, diagnosis, management, and prognosis. Secondary AHF occurring after non-cardiac surgery warrants particular attention due to its very high mortality rates of up to 44% within 1 year and is therefore the focus of this review. The scope of this document is to summarize the available evidence regarding the pathophysiology, prevention, diagnosis, treatment, and prognosis of AHF after non-cardiac surgery. Key to prevention is understanding and addressing the pathophysiology of AHF after non-cardiac surgery, which involves close monitoring of fluid status to avoid volume overload and/or hypovolemia, avoiding hypo- and/or hypertension, treating pain and anaemia to prevent tachycardia, and avoiding electrolyte disturbances to prevent arrhythmias. Cardiac biomarkers, such as cardiac troponins and natriuretic peptides, serve as important diagnostic tools and enhance risk stratification in the perioperative setting. A low threshold to perform echocardiography in this population is suggested. Vigilant post-operative care is essential for the early recognition and treatment of AHF after non-cardiac surgery, which could help improve outcomes for patients.

Keywords: Acute heart failure; Heart failure; Natriuretic peptides; Non-cardiac surgery; Perioperative complications.

Graphical Abstract

Prevention, diagnosis, management and prognosis of acute heart failure after non-cardiac surgery. HF, heart failure; COPD, chronic obstructive pulmonary disease; PAD, peripheral artery disease; CAD, coronary artery disease; AF, atrial fibrillation; PMI, perioperative myocardial infarction/injury; BNP, B-type natriuretic peptide; NT-proBNP, N-terminal pro-B-type natriuretic peptide.

Figure 1

Pathophysiology of acute heart failure after non-cardiac surgery. CRH, corticotropin-releasing hormone; ACTH, adrenocorticotropic hormone; IL, interleukin; TNFα:, tumour necrosis factor-alpha; CRP, C-reactive protein; RAA, renin–angiotensin–aldosterone; HF, heart failure; COPD, chronic obstructive pulmonary disease; PAD, peripheral artery disease; CAD, coronary artery disease; AF, atrial fibrillation; LV, left ventricle; LA, left atrium

Figure 2

Proposed algorithm for pre-operative risk assessment in patients with known HF. *If not performed in the last 6 months. ECG, electrocardiogram; hs-cTn, high-sensitivity cardiac troponin; NP, natriuretic peptides; NYHA, New York Heart Association; HF, heart failure

Figure 3

Pre-operative risk stratification in general. Modified from Halvorsen et al. CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram; NCS, non-cardiac surgery. *Class I recommendation according to the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. **Class IIa recommendation according to the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. CV risk factors: hypertension, smoking, dyslipidemia, diabetes, family history of CVD. Biomarkers: hs-cTn T/I and/ or BNP/NT-proBNP. Functional capacity based on Duke Activity Status Index (DASI) or the ability to climb two flights of stairs

Figure 4

Perioperative myocardial infarction/injury systematic work-up. Modified From Halvorsen et al. ECG, electrocardiogram; ST, ST-segment; MI, myocardial infarction; ICA, invasive coronary angiography; Hb, haemoglobin; CCTA, coronary computed tomography angiography. ^aOr active bleeding. ^bOther Type 2 MI trigger such as hypoxaemia, tachycardia, and hypertension. ^cDual antiplatelet therapy after coronary stenting. ^dPossibly in combination with dabigatran 110 mg b.i.d. Most patients with Type 2 MI and silent Type 1 MI should be scheduled for stress imaging or CCTA/ICA as outpatients after discharge, depending on symptoms prior to or after surgery and known CAD

Figure 5

Management of patients with AHF after non-cardiac surgery. Modified from McDonagh TA et al. ECG, electrocardiogram; SIRS, systemic inflammatory response syndrome; MCS, mechanical cardiac support. ^a1 mg/kg or 50% of the total daily oral dose previously administered. ^bInitial exams: troponin, serum creatinine, electrolytes, blood urea nitrogen or urea, haemoglobin. ^cSampling, liberal imaging to search for infect, as well as liberal introduction of antibiotics. ^dAdditional arguments for inotropes vs vasopressors: low diastolic blood pressure = vasopressors preferred; proportional pulse pressure ≤25% = inotropes preferred. ^eUrine output >100–150 mL/h during the first 6 h; if monitoring not possible, at least 2–3 times diuresis within 2 h. ^fAcetazolamide 500 mg i.v. or p.o. for 3–5 days OR metolazone 5 mg p.o. for 3–5 days. ^gPreferable norepinephrine.