Nearly half of HF cases undiagnosed before noncardiac surgery
Data from a medical records review suggest that nearly half of cases of preoperative HF remain undiagnosed before patients undergo noncardiac surgery, suggesting efforts to improve preoperative diagnosis are needed.
“During the preoperative surgical evaluation, a wealth of health data (eg, comprehensive history and clinical examination, laboratory test results, cardiovascular system investigations) are routinely collected, and represent an opportunity for enhanced diagnosis of HF,” Michael R. Mathis, MD, assistant professor in the department of anesthesiology, University of Michigan, and colleagues wrote in the study background. “This importance is underscored by findings showing that among patients with heart failure detected by rule-based electronic health record algorithms, a failure to diagnose and document heart failure preoperatively is associated with increased length of stay and mortality. Although identifying heart failure preoperatively has the potential to improve outcomes after noncardiac surgery, data are lacking as to the accuracy of heart failure diagnoses by clinicians during preoperative evaluations.”
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In an observational study, Mathis and colleagues analyzed data from 511 adults who underwent major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of HF was defined using patient history, clinical examination data or administrative documentation from a review of health records for patients with and without clinically diagnosed HF.
The findings were published in BJA Open.
Within the cohort, prevalence of HF was 9.1% based on clinical diagnosis compared with 13.3% (95% CI, 10.3-16.2) estimated by the expert panel. Among HF experts, overall agreement was 95% and inter-rater reliability was 0.79.
Based upon expert adjudication, HF was clinically diagnosed with an accuracy of 92.8% (95% CI, 90.6-95.1), with a sensitivity of 57.4% (95% CI, 53.1-61.7), specificity of 98.3% (95% CI, 97.1-99.4), a positive predictive value of 83.5% (95% CI, 80.3-86.8) and a negative predictive value of 93.8% (95% CI, 91.7-95.9).
“Should differences in intraoperative heart failure-related practice patterns and postoperative outcomes be observed among patients with HF misdiagnoses, subsequent prospective interventional studies seeking to reduce preoperative misdiagnosis of HF are warranted,” the researchers wrote. “These may include studies which explore the impact of electronic health record-based preoperative screening algorithms for HF, with an emphasis on ‘false-negative’ and ‘false-positive’ patients identified in this study, and studies which explore the impact of goal-directed HF-related perioperative management strategies among commonly misdiagnosed patients.”
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