The prognostic implication of perioperative cardiac enzyme elevation in patients with fractured neck of femur: A systematic review and meta-analysis

Development and Internal Validation of a Nomogram for Predicting Postoperative Cardiac Events in Elderly Hip Fracture Patients

Purpose

Postoperative cardiac events (PCEs) are among the main adverse events after hip fracture surgery in the elderly. Existing cardiac risk assessment tools have some limitations and are not specifically designed for elderly patients undergoing hip fracture surgery. This study aimed to develop and internally validate a nomogram for prediction of PCEs in these patients.

Patients and Methods

We performed a retrospective study of 992 patients aged ≥65 years undergoing hip fracture surgery in our hospital from July 2015 to December 2021. Patients' demographics and clinical data were collected. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to select predictors, and multivariate logistic regression was employed to construct a nomogram. Internal validation was performed by bootstrapping. The discriminatory ability of the model was determined by the area under the receiver operating characteristic curve (AUC). The calibration and clinical utility of the model were assessed. The predictive power and clinical benefit of the nomogram were compared with the Revised Cardiac Risk Index (RCRI).

Results

The nomogram was constructed including seven variables: general anesthesia, the American Society of Anesthesiologists (ASA) classification, history of heart failure, history of severe arrhythmia, history of coronary artery disease, preoperative platelet count, and serum creatinine. The nomogram had an excellent predictive ability (AUC = 0.875, 95% confidence interval [CI]: 0.828-0.918). Satisfactory calibration was shown by calibration plots and the Hosmer-Lemeshow goodness-of-fit test (P = 0.520). Clinical usefulness was confirmed by decision curve analysis and clinical impact curve. The predictive power and clinical utility of the nomogram were superior to RCRI.

Conclusion

We developed an easy-to-use nomogram for prediction of PCEs in elderly hip fracture patients. This prediction model could effectively identify patients at high risk of PCEs and may be useful for perioperative management optimization.

Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study

Introduction  The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods  This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States). Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions.  Results  During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment. Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022). At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%).  Conclusion  Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.

Evaluation of the cardiovascular risk in patients undergoing major non-cardiac surgery: role of cardiac-specific biomarkers

Major adverse cardiovascular events are frequently observed in patients undergoing major non-cardiac surgery during the peri-operative period. At this time, the possibility to predict cardiovascular events remains limited, despite the introduction of several algorithms to calculate the risk of adverse events, mainly death and major adverse cardiovascular events (MACE) based on the clinical history, risk factors (sex, age, lipid profile, serum creatinine) and non-invasive cardiac exams (electrocardiogram, echocardiogram, stress tests). The cardiac-specific biomarkers natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the peri-operative period, particularly for the identification of myocardial injury in patients undergoing major non-cardiac surgery. The prognostic information from the measurement of BNP/NT-proBNP and hs-cTn is independent and complementary to other important indicators of risk, also including ECG and imaging techniques. Elevated levels of cardiac-specific biomarkers before surgery are associated with a markedly higher risk of MACE during the peri-operative period. BNP/NT-proBNP and hs-cTn should be measured in all patients during the clinical evaluation before surgery, particularly during intermediate- or high-risk surgery, in patients aged >65 years and/or with comorbidities. Several questions remain to be assessed in dedicated clinical studies, such as how to optimize the management of patients with raised cardiac specific biomarkers before surgery, and whether a strategy based on biomarker measurement improves patient outcomes and is cost-effective.

Natriuretic Peptides and Troponins to Predict Cardiovascular Events in Patients Undergoing Major Non-Cardiac Surgery

Patients undergoing major surgery have a substantial risk of cardiovascular events during the perioperative period. Despite the introduction of several risk scores based on medical history, classical risk factors and non-invasive cardiac tests, the possibility of predicting cardiovascular events in patients undergoing non-cardiac surgery remains limited. The cardiac-specific biomarkers, natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the perioperative period. This review paper aims to discuss the value of preoperative levels and perioperative changes in cardiac-specific biomarkers to predict adverse outcomes in patients undergoing major non-cardiac surgery. Based on several prospective observational studies and six meta-analyses, some guidelines recommended the measurement of NPs to refine perioperative cardiac risk estimation in patients undergoing non-cardiac surgery. More recently, several studies reported a higher mortality in surgical patients presenting an elevation in high-sensitivity cardiac troponin T and I, especially in elderly patients or those with comorbidities. This evidence should be considered in future international guidelines on the evaluation of perioperative risk in patients undergoing major non-cardiac surgery.

Tranexamic Acid Use During Surgery Associated with Extension of Acute Perioperative Type 1 Myocardial Infarction: A Case Report

CASE PRESENTATION

A 70-year-old women presented to a regional hospital after a fall, resulting in a periprosthetic femoral fracture. Preoperative echocardiogram was ordered to investigate a cardiac murmur, and unexpectedly, a significant regional wall abnormality was found. Further repeat electrocardiograph and troponin blood biomarker analysis demonstrated the patient had suffered an acute type 1 myocardial infarction after admission to the ward, without exhibiting classical ischemic cardiac symptoms. A multidisciplinary decision was made for the patient to proceed to surgery, and at that time, she received tranexamic acid (TXA). Postoperatively, there was notable echocardiographic extension of the infarction, which required transfer to a tertiary center for management with complex coronary artery stenting. The patient once discharged was followed up by cardiology at the 3-month interval.

CONCLUSION

The use of TXA in arterial thromboembolic disease requires thorough consideration because it may contribute to further myocardial damage. A patient-specific approach should be adopted with the risk of thrombosis extension being considered.