Patients With Heart Failure Report Excellent Outcomes After Hip or Knee Replacement

Patients with heart failure can safely undergo hip or knee replacement surgery and experience similar improvement in joint pain and function as patients without heart failure, indicate two Cleveland Clinic studies.

“With thoughtful optimization and care coordination, we can help the growing population of people with comorbid osteoarthritis and heart disease regain mobility and independence,” says senior author Nicolas S. Piuzzi, MD, Enterprise Vice Chair of Research for Orthopaedics and Rehabilitation at Cleveland Clinic.

Due to advancements in the treatment of both heart failure and joint pain in recent decades, it’s important to understand care pathways for patients with both conditions, he says. Joint problems can directly affect a patient’s ability to perform exercise as part of cardiac rehabilitation.

“We all want our patients to have the best quality of life,” says study coauthor Paulino Alvarez, MD, a heart failure specialist at Cleveland Clinic. “Sometimes I see patients with heart failure who have been suffering with joint pain that limits their quality of life. Many centers refuse joint replacement surgery for these patients because of their history of heart failure and risk of complications. At the same time, these patients are contraindicated for NSAIDs, a mainstay in treating osteoarthritis pain. These patients need an alternative to living with pain. That’s why we pursued these clinical studies.”

More healthcare use but excellent outcomes

In the retrospective study of more than 12,000 patients who had total knee replacement (TKR) at Cleveland Clinic between 2016 and 2021, nearly 500 had heart failure (Eur J Orthop Surg Traumatol. 2025 Oct 9;35(1):424).

After TKR, patients with heart failure had a higher risk of:

• Hospital stay of three days or longer (OR 2.55, P < .001)
• Nonhome discharge (OR 2.17, P < .001)
• Hospital readmission within 90 days (OR 2.02, P < .001)
• Emergency department visit within 90 days (OR 1.55, P = .002)
• Mortality within one year (3.23% vs. 0.50%; OR 3.53, P = .007)

However, one year after surgery, these patients reported favorable outcomes similar to patients without heart failure.

Knee Injury and Osteoarthritis Outcome Scores, 1 Year After TKR

*On a scale of 0-100, where 100 is best knee health

These findings in knee arthroplasty were echoed in a separate but similar study of hip arthroplasty. Out of nearly 11,000 patients who had total hip replacement (THR) at Cleveland Clinic between 2016 and 2021, nearly 400 had heart failure (J Arthroplasty. 2025 Aug 6:S0883-5403(25)00977-5).

After THR, patients with heart failure had a higher risk of:

• Hospital stay of three days or longer (OR 2.12, P < .001)
• Nonhome discharge (OR 1.61, P = .003)
• Mortality within one year (OR 3.40, P = .008)

The slight rise in one-year mortality aligns with the expected course of heart failure and is not considered a cause for concern relative to surgical safety or benefit, notes Dr. Piuzzi.

One year after surgery, patients with heart failure achieved pain and function improvements comparable to those without heart failure.

Hip Disability and Osteoarthritis Outcome Scores, 1 Year After THR

**On a scale of 0-100, where 100 is best hip health

“We were not surprised to see that patients with heart failure in both cohorts had higher healthcare utilization and higher mortality rates. That was expected,” Dr. Piuzzi says. “However, most patients with heart failure ultimately walked away from knee and hip replacement with excellent improvement in pain and function, comparable to patients without heart failure.”

Ejection fraction cannot predict outcomes

Both knee and hip studies stratified patients with heart failure by severity of left ventricular ejection fraction:

• Preserved (≥ 50%)
• Mildly reduced (41%-49%)
• Reduced (≤ 40%)

Both studies found that ejection fraction had no association with patient-reported pain and function outcomes. Neither was it associated with healthcare utilization.

“Patients achieved similar improvement in joint pain and function regardless of the severity of their heart failure,” Dr. Alvarez says. “Even patients with severe heart failure showed substantial benefit from joint replacement. This finding suggests that arthroplasty can be safely performed and should be an option for well-selected patients with any level of heart failure.”

Optimizing heart patients for joint replacement

A multidisciplinary approach, careful planning and patient optimization before surgery are essential to ensuring the best outcomes for heart patients considering joint replacement, say the authors.

“From an orthopaedic standpoint, our surgical techniques for hip or knee replacement are the same no matter the patient,” Dr. Piuzzi says. “What differs is in how we prepare the patient for surgery, how we coordinate with anesthesia and how we manage the patient after surgery. Patients who have LVADs [left ventricular assist devices] or who take high doses of anticoagulation medications do require more attention from both the cardiology and orthopaedic teams. These patients can recover well from orthopaedic surgery, but their care pathways must be individualized.”

A patient with heart failure who has good functional capacity, shows no signs of decompensation and is on optimized guideline-directed medical therapy is usually a good candidate for joint replacement, notes Dr. Alvarez. However, evaluating functional capacity in patients with severe joint pain can be challenging, and clinical judgment based on a thorough history and physical examination is paramount.

“In our clinic, postoperative care for patients with heart failure starts during the preoperative visit, when we create a personalized plan based on the complexity, severity and other characteristics of the heart failure syndrome,” Dr. Alvarez says. “The main components of this plan include patient education and close follow-up after surgery. If a patient is recovering well, we usually prefer to conduct a virtual postoperative visit to discuss any needed medication adjustments and answer questions. This method helps avoid disrupting postoperative physical therapy and rehabilitation. However, if we observe any concerning symptoms, such as lightheadedness related to low blood pressure or rapid weight gain (3 lb. in three days or 5 lb. in five days), we will see the patient in clinic. We also stay in contact with our orthopaedic colleagues. If they have any concerns about the patient’s clinical status, we will promptly schedule a visit with the patient.”

Arthroplasty is an option for patients with heart failure

Patients with heart failure may require more care after arthroplasty, but that should not deter them from having the surgery, says Dr. Piuzzi.

“Patients with complex conditions sometimes need a higher level of care,” he says. “Despite that, they still can have excellent outcomes. Joint replacement should not be viewed as a luxury or merely an improvement in quality of life. Having a functional, pain-free joint has broad implications, including being able to independently get out of bed, go to the bathroom, go to the store — performing basic human tasks, even cardiac rehabilitation.”

Adds cardiologist Amanda Vest, MBBS, Section Head of Heart Failure and Recovery at Cleveland Clinic, “Optimizing joint health is a particularly important consideration for our patients with heart failure because we know that regular physical activity is highly beneficial for people living with this cardiac condition. A knee or hip replacement can be a key step in enabling patients to keep active and improve their cardiovascular fitness.”