Heart Failure and Perioperative Care

Over the next 10 years, it is estimated that more than 20% of the US population will be older than 65 years. Globally, older patients comprise an ever-expanding proportion of more than 234 million surgical procedures performed each year. This demographic group is overrepresented in major surgery, particularly for malignancy. With increasing age, cardiac reserve and function decline. The overall prevalence of heart failure in patients older than 45 years is estimated at 2.2%. However, with age, this picture changes dramatically. The Framingham Heart Study found a prevalence of heart failure in men of 8 per 1,000 between the ages of 50 and 59 years, which subsequently increased eight-fold by the ninth decade. Broadly similar increases in prevalence have been reported in women. The prevalence in African Americans is around 25% higher than in whites. The American Heart Association estimated that there were 5.1 million people with heart failure in the United States in 2006, and this estimate has certainly risen, given predicted increases in life expectancy. In addition to the increasingly elderly population exhibiting overt cardiac failure, it has become apparent that many patients present for surgery with poor cardiopulmonary reserve that physiologically resembles many features of heart failure, albeit without the formal recognition of this syndrome. Recent epidemiological data demonstrate that for patients with an established diagnosis of heart failure, perioperative morbidity and mortality are increased. Most importantly, the risk conferred by heart failure appears to outweigh other preoperative morbidities that have attracted more academic and clinical attention (Supplemental Digital Content 1, http://links.lww. com/ASA/A537). Heart failure encompasses a complex multiorgan syndrome, and its cardiac and extracardiac pathophysiological features present many perioperative challenges.