Introduction

Preventing the recurrence of hospitalizations due to exacerbations of Heart Failure (HF) has been a primary focus for intervention efforts, given their detrimental impact on quality of life and increased mortality risk. Despite the implementation of initiatives like the Hospital Readmission Reduction Program (HRRP), which have been associated with reductions in national readmission rates, some analyses have indicated a notable rise in 30-day post-discharge mortality subsequent to HF hospitalizations. The direct causal link between HRRP and this outcome remains uncertain, raising concerns about potential prioritization of readmission reduction over patient well-being. This underscores the necessity for a more patient-centered, patient-sensitive, and health-focused approach. Recent research has shifted focus towards individual patient clinical factors rather than solely examining hospital- and community-based programs. This shift aims to gain deeper insights into recurrence risk and to develop more efficacious interventions. Precipitating Factors (PFs), encompassing both patient behaviors and factors necessitating treatment adjustments, play a crucial role in assessing risk. PFs are identified in a significant percentage of Acute HF (AHF) episodes, and their specific presence has been suggested to influence the likelihood of adverse events. Therefore, evaluating PFs is recommended in clinical practice guidelines to guide treatment planning and optimize disease management. Particularly, addressing patients' behavioral factors may represent a pivotal target for additional support. Nevertheless, large-scale studies, particularly those meticulously documenting PFs with a specific emphasis on patients' adherence behavior, remain limited.

Risk factors

This research aimed to explore the characteristics of Preoperative Factors (PFs) to enhance our comprehension of their potential association with the natural progression of Acute Heart Failure (AHF), encompassing outcomes such as in-hospital mortality, rehospitalization due to heart failure over time, and all-cause mortality post-discharge. Heart failure stands as one of the primary risk factors for adverse events subsequent to noncardiac surgeries, correlating independently with significant complications, prolonged postoperative hospital stays, increased readmissions, and elevated postoperative mortality rates. Despite advancements in heart failure treatments, accurately diagnosing the condition in a timely manner remains challenging due to the diverse clinical presentations and progression trajectories of the disease. Studies examining both hospitalized patients and outpatients reveal that a considerable proportion of individuals with sufficient electronic health record data to define heart failure do not receive a definitive diagnosis. These findings collectively indicate that an accurate preoperative identification of heart failure, if resulting in enhanced perioperative management and prompt initiation of guideline-recommended medical therapies known to reduce mortality, could potentially yield significant public health benefits, particularly considering the vast number of noncardiac surgical procedures performed globally each year, exceeding 300 million. During the preoperative surgical evaluation, a wealth of health data are routinely collected, and represent an opportunity for enhanced diagnosis of heart failure. The significance of this issue is highlighted by research indicating that failure to diagnose and document heart failure prior to surgery, particularly among patients identified through electronic health record algorithms, is linked to prolonged hospital stays and higher mortality rates. While early identification of heart failure before surgery holds potential for improving outcomes in noncardiac surgical procedures, there is a lack of data regarding the accuracy of heart failure diagnoses made by clinicians during preoperative assessments. To address this gap, we conducted an observational cohort study aimed at evaluating the precision of clinical diagnoses of heart failure in the preoperative setting.

Heart failure

The objectives of our study were twofold: firstly, to compare the accuracy of heart failure diagnoses documented before surgery with those determined through expert evaluation; and secondly, to examine the characteristics of patients who were misdiagnosed with heart failure. To ensure consistency in adjudicated diagnoses, experts speci ically focused on assessing for chronic Stage C or Stage D heart failure according to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Conversely, Stage B heart failure, which denotes structural heart disease without current or prior symptoms of heart failure, was adjudicated as not being heart failure. For adjudicated heart failure diagnoses, the reference time point was set as the date of surgery prior to the operation. Conversely, a preoperative clinical diagnosis of heart failure was defined as either explicit mention of heart failure in the preoperative anesthesia history and clinical examination or the presence of an International Classification of Diseases (ICD) code for heart failure. Additionally, a sensitivity analysis was conducted, which expanded the clinical diagnosis criteria to include patients with a preoperative left ventricular ejection fraction ≤ 40%, a diagnosis code for cardiomegaly, or hypertrophic cardiomyopathy. This sensitivity analysis aimed to encompass patients with ACC/AHA Stage B heart failure, a subgroup likely to be diagnosed with heart failure preoperatively.