Discontinuation of Heart Failure Therapy in patients Undergoing Non-Cardiac surgery: Data from a Real-world Cohort

Background and Aims Patients with heart failure (HF) with reduced ejection fraction (HFrEF) are at high risk for cardiovascular events following non-cardiac surgery. The perioperative period represents many challenges to maintain guideline directed medical therapy (GDMT). We examined GDMT use in HFrEF patients following non-cardiac surgery, and the association of medication changes with cardiovascular outcomes. Methods Using linked administrative databases, a retrospective cohort of HFrEF patients undergoing major non-cardiac surgery between 2008 and 2020 was formed. Pre-operative use of GDMT was determined by outpatient prescriptions up to 90 days prior to surgery. Changes in GDMT was defined as discontinuation or a dose reduction (≥50%) of baseline therapies at 90 days after discharge. The primary composite outcome was HF hospitalization or all-cause mortality at one-year adjusted for age, sex, components of the Revised Cardiac Risk Index and the Charlson Comorbidity index. Results Of 397,829 index surgeries, there were 7667 (2%) patients with pre-existing HFrEF on at least one GDMT (50.6% female; mean age: 75 +/- 12 years). At 90 days post-operatively, 46% of patients had undergone major changes to GDMT. Compared to patients who continued GDMT, patients with any change to therapy had a higher incidence of the primary outcome (52% vs. 46%, aOR: 1.14, 95% CI: 1.03-1.25) and all-cause mortality at one year (8.5% vs. 4.9%, aOR: 1.57, 95% CI: 1.3-1.90). Conclusion Among patients with HFrEF undergoing major non-cardiac surgery, few are on optimal GDMT, and perioperative changes to GDMT is associated with higher odds for HF hospitalization or death.