Perioperative risk assessment and therapeutic consequences

BACKGROUND: Three million people in Germany, and approximately 20% of older people undergoing surgery, suffer from chronic congestive heart failure. Perioperative hospital mortality is 4.8% in patients known to have chronic congestive heart failure and only 0.78% in other patients (adjusted odds ratio 2.15, 95% confidence interval [2.09; 2.22]). Congestive heart failure is often inadequately diagnosed and treated, and there is often a lack of preoperative guideline-based risk assessment and individualized strategic planning. METHODS: This narrative review is based on pertinent guidelines and publications retrieved by a selective literature search (PubMed/Medline). RESULTS: The frequency of acute postoperative decompensation is 2.5% among the entire population of patients with congestive heart failure (whether newly diagnosed or previously present as a chronic condition). The 1-year mortality rate is 44% (which can be compared to 11% without cardiac decompensation; adjusted HR, 1.66 [1.3; 2.2]). Patients at risk should be identified and classified at an early stage with biomarker screening and echocardiography so that they can be managed perioperatively in accordance with the guidelines. Extended cardiovascular monitoring (preload, contractility, afterload) enables individualized volume and fluid substitution. Frequent reexamination in the early postoperative phase allows clinical deterioration to be detected early and treated with drugs. After discharge, the patient's further course must be monitored by his or her primary care physician. CONCLUSION: Guideline-based pharmacotherapy, risk stratification, and interdisciplinary perioperative monitoring at close intervals are indispensable for lowering risk and preventing acute decompensation. Randomized clinical trials have been performed for the general treatment of congestive heart failure, but not for its perioperative management.