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Vacheron CH, Hentzen J, Fauvernier M, Fessy M, Chaudier P, Landel V, David JS, Incagnoli P, Piriou V, Friggeri A. Association Between Short-, Intermediate-, and Long-term Mortality and Myocardial Injury After Noncardiac Surgery After Hip Fracture Surgery: A Retrospective Cohort. Anesth Analg 2021; 133:915-923. [PMID: 33830947 DOI: 10.1213/ane.0000000000005528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND For more than 20 years, hip fracture 1-year mortality has remained around 20%. An elevation of the postoperative troponin peak within 72 hours (myocardial injury after noncardiac surgery [MINS]) is associated with a greater risk of short-term mortality in the general population. However, there seem to be conflicting results in the specific population who undergo hip fracture surgery, with some studies finding an association between troponin and mortality and some not. The objective of the present study was to investigate the association of MINS and the short- (before 28th day), intermediate- (before 180th day), and long-term (before 365th day) mortality after hip fracture surgery. METHODS We conducted a single-center retrospective cohort of patients undergoing hip fracture surgery from November 2013 to December 2015. MINS was defined as postoperative troponin peak within the 72 hours >5 ng/L. Four MINS subgroups were defined according to the value of troponin peak (ie, ≥5-<20, ≥20-<65, ≥65-<1000, and ≥1000 ng/L). To document the association between the different mortality terms and the troponin peak, odds ratio (OR) and adjusted OR (aOR) associated with their 95% confidence interval (CI) with the log of the scaled troponin peak within 72 hours were estimated, with and without patients presenting a postoperative acute coronary syndrome (ACS). Cox proportional hazards modeling was used to estimate hazard ratio (HR) and adjusted HR (aHR) of death between the no MINS and MINS subgroups. The adjustment was performed on the main confounding factors (ie, sex, American Society of Anesthesiologists [ASA] physical status, dementia status, age, and time from admission to surgery). RESULTS Among 729 participants, the mean age was 83.1 (standard deviation [SD] = 10.8) years, and 77.4% were women; 30 patients presented an ACS (4%). Short-, intermediate-, and long-term mortality were at 5%, 16%, and 23%, respectively. The troponin peak was significantly associated with all terms of mortality before and after adjustment and before and after exclusion of patients presenting an ACS. HR and aHR for each subgroup of troponin level were significantly associated with an increased probability of survival, except for the 5 to 20 ng/L group for which aHR was not significant (1.75, 95% CI, 0.82-3.74). In the landmark analysis, there was still an association between survival at the 365th day and troponin peak after the short- and intermediate-term truncated mortality. CONCLUSIONS MINS is associated with short-, intermediate-, and long-term mortality after hip fracture surgery. This could be a valuable indicator to determine the population at high risk of mortality that could benefit from targeted prevention and possible intervention.
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Affiliation(s)
- Charles-Hervé Vacheron
- From the Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France.,Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique - Bioinformatique, Lyon, France.,Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Julie Hentzen
- Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Fauvernier
- From the Unité Mixte de Recherche 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France.,Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique - Bioinformatique, Lyon, France
| | - Michel Fessy
- Département de Chirurgie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
| | - Philippe Chaudier
- Département de Chirurgie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
| | - Verena Landel
- Hospices Civils de Lyon, Direction de la Recherche Clinique et de l'Innovation, Lyon, France
| | - Jean Stephane David
- Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Pascal Incagnoli
- Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Vincent Piriou
- Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Friggeri
- Département d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
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Takotsubo Syndrome: Is this a Common Occurrence in Elderly Females after Hip Fracture? J Crit Care Med (Targu Mures) 2020; 6:146-151. [PMID: 32864459 PMCID: PMC7430354 DOI: 10.2478/jccm-2020-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/31/2020] [Indexed: 01/24/2023] Open
Abstract
Background The prevalence of Takotsubo syndrome in hip fracture is not known. Methods Hip fracture patients were evaluated in a multidisciplinary unit. Patients with ECG abnormalities and increased troponin I values at the time of hospital admission were included in the study Follow-up was clinical at 30 days and by telephonic interview at one year. Results Between October 1st 2011 to September 30th 2016, 51 of 1506 patients had preoperative evidence of myocardial damage. Eight, all females, fulfilled the Mayo criteria for Takotsubo syndrome, six had no coronary lesions. Hip surgery was uneventful, and all eight were alive at thirty days, and seven of these were still alive after one year. Forty-three patients had myocardial infarction: mortality at thirty days and one year were 11% and 44% (p<0.0001, Student's t-test; log-rank test). Conclusion At least 15% of patients with hip fracture and preoperative myocardial damage had Takotsubo syndrome. They were all elderly females. Contrary to myocardial infarction, Takotsubo syndrome has a favourable long term prognosis.
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Araguas MA, Herrera A, Garrido I, Mateo J, Mayoral AP, Muñoz M. Risk factors for major adverse cardiovascular events after osteoporotic hip fracture repair surgery. Injury 2020; 51 Suppl 1:S30-S36. [PMID: 32360086 DOI: 10.1016/j.injury.2020.03.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
Osteoporotic hip fracture (OHF) is an increasingly frequent age-related pathology, which results in high rates of functional loss and mortality within the first year after surgery. This study assessed whether preoperative levels of brain natriuretic peptide (NT-proBNP) and troponin I were related to early occurrence (30d) of major adverse cardio-vascular events (MACE) after OHF repair surgery. During a 6-month period, perioperative clinical and analytical data from consecutive patients, without known history of cardiovascular disease and undergoing surgery for OHF repair at a single centre, were prospectively collected. MACE was defined as acute myocardial ischaemia or infarction, acute heart failure or cardiovascular death. amongst the 140 patients included, 23 (16.4%) developed postoperative MACE (MACE group) and 117 did not (Control group). Compared to those from control group, patients from MACE group were older, had poorer physical status (ASA III-IV), received preoperative red blood cell transfusion (RBCT) more frequently, presented with lower haemoglobin concentrations and higher NT-proBNP, creatinine and troponin I concentrations. Overall, RBCT requirements and 30d mortality rate were also higher in MACE group. However, in multivariate analysis, only preoperative RBCT, creatinine >1 mg/dL and NT-proBNP >450 pg/mL remained as independent preoperative risks factors for postoperative MACE, while 95% confidence intervals of odds ratios were wide. Though our findings require confirmation in a larger multicentre cohort, identifying risk factors for early postoperative MACE after OHF repair surgery, might facilitate assessing patients' risk prior to and following surgery, and targeting them the appropriate preventive and/or therapeutic interventions.
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Affiliation(s)
- M A Araguas
- Department of Cardiology, Royo Villanova Hospital, Zaragoza, Spain
| | - A Herrera
- Department of Surgery, University of Zaragoza, Zaragoza, Spain; Aragón's Health Research Institute, Zaragoza, Spain.
| | - I Garrido
- Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital, Zaragoza, Spain
| | - J Mateo
- Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital, Zaragoza, Spain
| | - A P Mayoral
- Health Sciences School, University of Zaragoza, Zaragoza, Spain
| | - M Muñoz
- Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
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Lowe MJ, Lightfoot NJ. The prognostic implication of perioperative cardiac enzyme elevation in patients with fractured neck of femur: A systematic review and meta-analysis. Injury 2020; 51:164-173. [PMID: 31879176 DOI: 10.1016/j.injury.2019.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/11/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neck of Femur (NOF) fractures are a common injury in comorbid elderly patients which are associated with increased rates of morbidity and mortality following fracture. Because of their injury, patients can experience reductions in quality of life and independent living leading to transfer to nursing home or dependent levels of care. Numerous factors are associated with either complications or reductions in survival following fractured NOF. From the VISION cohort there is evidence that troponin elevation in the post-operative period following a diverse range of non-cardiac surgical procedures may lead to an increased risk of mortality in the absence of classical ischaemic or cardiac symptoms. The aim of this systematic review and meta-analysis is to validate the utility of perioperative troponin elevation as a prognostic indicator for mortality and cardiac morbidity in those with fractured NOF. METHODS The PRISMA guidelines for the conduct of meta-analyses were followed. An electronic search was conducted of the EMBASE, MEDLINE (Ovid) and Biosis databases. Studies were included for analysis if they stratified outcomes by perioperative troponin elevation in surgically managed fractured NOF and reported sufficient data on troponin elevation and mortality following surgery. Primary and secondary outcomes assessed were all-cause post-operative mortality and a composite measure of cardiac complications (myocardial infarction, cardiac failure and arrhythmia) respectively. RESULTS Eleven studies met inclusion criteria giving a total of 1363 patients. Overall, 497 patients (36.5%) experienced an elevation in troponin levels following surgery. Perioperative troponin elevation was significantly associated with all-cause mortality (OR 2.6; 95% CI 1.5 - 4.6; p <0.001) and cardiac complications (OR 7.4; 95% CI 3.5 - 15.8; p <0.001). Patient factors significantly associated with troponin elevation included pre-existing coronary artery disease, cardiac failure, hypertension, previous stroke and previous myocardial infarction. CONCLUSION Perioperative troponin elevation is significantly associated with increased mortality and post-operative cardiac complications following fractured NOF and may be a useful prognostic indicator in these patients. Future research should further stratify patients by the magnitude of troponin elevation and further refine the risk factors.
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Affiliation(s)
- Matthew J Lowe
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.
| | - Nicholas J Lightfoot
- Department of Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
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Chen X, Ma Y, Deng Z, Li Q, Liao J, Zheng Q. Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report. Clin Interv Aging 2020; 15:755-762. [PMID: 32546993 PMCID: PMC7266334 DOI: 10.2147/cia.s250620] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients. PATIENTS AND METHODS From January 2014 to January 2019, the medical records of all surgically treated elderly patients (>65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure >25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) <50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality. RESULTS There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332-8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869-17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047-1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002-185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988-51.413, p=0.040) and LVEF <50% (OR:8.803, 95% CI: 1.115-69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality. CONCLUSION Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF <50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.
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Affiliation(s)
- Xuepan Chen
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Shantou University Medical College, Shantou, People’s Republic of China
| | - Yuanchen Ma
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Zhantao Deng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qingtian Li
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - JunXing Liao
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
| | - Qiujian Zheng
- Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences;School of Medicine, South China University of Technology, Guangzhou, People’s Republic of China
- Correspondence: Qiujian Zheng Department of Orthopedics, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, No. 106, Zhongshan Second Road, Yuexiu District, Guangzhou510000, People’s Republic of China Email
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Smeets SJM, van Wunnik BPW, Poeze M, Slooter GD, Verbruggen JPAM. Cardiac overscreening hip fracture patients. Arch Orthop Trauma Surg 2020; 140:33-41. [PMID: 31471640 PMCID: PMC6942037 DOI: 10.1007/s00402-019-03270-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome. METHODS This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality. RESULTS According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality. CONCLUSION Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality. LEVEL OF EVIDENCE II.
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Affiliation(s)
- S. J. M. Smeets
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA Almere, The Netherlands
| | - B. P. W. van Wunnik
- Department of Surgery, Beatrixziekenhuis, Banneweg 57, 4204 AA Gorinchem, The Netherlands
| | - M. Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G. D. Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, The Netherlands
| | - J. P. A. M. Verbruggen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Rostagno C, Peris A, Polidori GL, Ranalli C, Cartei A, Civinini R, Boccaccini A, Prisco D, Innocenti M, Di Mario C. Perioperative myocardial infarction in elderly patients with hip fracture. Is there a role for early coronary angiography? Int J Cardiol 2019; 284:1-5. [DOI: 10.1016/j.ijcard.2018.10.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 10/28/2022]
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Usefulness of Serum Cardiac Biomarkers for Predicting In-Hospital Cardiac Complications in Acute Hip Fracture: A Prospective Cohort in 20 High Surgical Risk patients with Age over 55 Years. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3453652. [PMID: 30069466 PMCID: PMC6057424 DOI: 10.1155/2018/3453652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/11/2018] [Accepted: 05/31/2018] [Indexed: 12/23/2022]
Abstract
Background. Serum cardiac biomarkers have recently been demonstrated to be useful for predicting perioperative complication after hip fracture (HF). However, no previous study has revealed the comparative efficacy of different cardiac biomarkers in high surgical risk HF patients. Methods. A prospective study was conducted, from June to December 2016, in 20 acute HF patients with American Society of Anesthesiologists (ASA) grade 3 or 4. All patients received blood test for high sensitivity Troponin-I (hsTnI) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) at the time of admission and 24 hours postoperatively. Perioperative data and in-hospital, 3-month, and 6-month postoperative complications were collected. The complications were classified as cardiac and noncardiac HF-related complications. Results. The average patients' age was 79±8 years. Six patients (30%) were male. The incidence of PCI was 30% (n=6). None of the patients (0%) died during the 6-month postoperative followup period. In-hospital overall cardiac and noncardiac complications were found in 12(60%), 5(30%), and 7(45%), respectively. The mean serum hsTnI levels in the patients with cardiac complication were significantly greater than those in the patients without cardiac complication at both time of admission (99.5 ng/mL vs 5.5 ng/mL, p=0.006) and 24 hours postoperatively (28.6 ng/mL vs 9.4 ng/mL, p=0.013). The mean serum NT-proBNP levels in patients with cardiac complication were also greater but nonsignificantly compared to those in the patients without cardiac complication at both time of admission (2299 pg/mL vs 281 pg/mL, p=0.239) and 24 hours postoperatively (2266 pg/mL vs 586 pg/mL, p=0.061). The other significant preoperative predictors for cardiac complication were low hemoglobin level (p=0.014), low glomerular filtration rate level (p=0.039), and ASA grade 4 (p=0.005). Conclusion. In-hospital cardiac complication in high-risk HF patients was significantly associated with the abnormal rise of serum hsTnI level. Therefore, we recommended using the hsTnI test in the perioperative evaluation in high-risk HF patients. Trial registration number is TCTR20160711002.
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Moppett IK, White S, Griffiths R, Buggy D. Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial. Trials 2017; 18:350. [PMID: 28743315 PMCID: PMC5526232 DOI: 10.1186/s13063-017-2066-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/24/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control. METHODS/DESIGN We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence. DISCUSSION This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study. TRIAL REGISTRATION ISRCTN Registry identifier: ISRCTN89812075 . Registered on 30 August 2016.
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Affiliation(s)
- Iain Keith Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stuart White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Griffiths
- Department of Anaesthesia, Peterborough & Stamford Hospitals NHS Trust, Peterborough, UK
| | - Donal Buggy
- School of Medicine, Mater Hospital, Eccles Street, Dublin 7, Ireland
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Hietala P, Strandberg M, Kiviniemi T, Strandberg N, Airaksinen KJ. Usefulness of troponin T to predict short-term and long-term mortality in patients after hip fracture. Am J Cardiol 2014; 114:193-7. [PMID: 24856320 DOI: 10.1016/j.amjcard.2014.04.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
The purpose was to evaluate the short-term (30-day) and long-term (1,000-day) prognostic values of perioperative troponin T (TnT) and electrocardiographic (ECG) findings in hip fracture patients. A consecutive cohort of 200 patients (68 men) was enrolled. Blinded TnT levels and ECG were assessed on admission, before operation, and on first and second postoperative days. Median (interquartile range) follow-up time was 3.1 (0.3) years. TnT elevation was observed in 71 patients (35.5%): already before the operation in 36 patients (51%) and only after surgery in 35 patients (49%). New ischemic ECG changes were detected in 101 of 194 patients (52%), including 7 ST elevations. Patients with TnT elevation had higher short-term (17% vs 4.7%, respectively, p=0.008) and long-term (61% vs 40%, respectively, p=0.005) mortality, the short-term mortality being higher in patients with major (TnT≥0.15 μg/L) compared with minor TnT elevation (24% vs 13%, respectively, p=0.005). TnT elevation was the only independent predictor of short-term mortality (hazard ratio [HR] 3.87, 95% confidence interval [CI] 1.45 to 10.3, p=0.007), whereas TnT elevation (HR 1.73, 95% CI 1.14 to 2.64, p=0.01), increasing age (HR 1.03, 95% CI 1.01 to 1.06, p=0.01), dementia (HR 1.84, 95% CI 1.22 to 2.78, p=0.004), and atrial fibrillation (HR 1.86, 95% CI 1.18 to 2.93, p=0.007) remained independent predictors of long-term mortality. ECG findings other than ST elevation did not affect mortality. In conclusion, elevated perioperative TnT level is a strong predictor of short-term and long-term mortality. Routine TnT measurements and earlier diagnosis together with appropriate treatment may improve survival of this fragile patient group.
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Sandhu A, Sanders S, Geraci SA. Prognostic value of cardiac troponins in elderly patients with hip fracture--a systematic review. Osteoporos Int 2013; 24:1145-9. [PMID: 22907738 DOI: 10.1007/s00198-012-2116-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 06/21/2012] [Indexed: 10/28/2022]
Abstract
Cardiac troponins can be elevated in cardiac ischemic conditions or other diseases such as pulmonary embolism or renal failure, where they may predict outcome. We hypothesized that cardiac troponins offer useful prognostic information regarding morbidity and mortality in elderly hip fracture patients undergoing surgical therapy. A literature review was conducted using PubMed and CINAHL plus with full text (EBSCOhost). Articles with original data relating troponins to prognosis in elderly hip fracture patients were reviewed. Studies with patients not undergoing surgery or undergoing elective or nonhip fracture surgery were excluded. Six papers met inclusion criteria. Troponin elevation was seen in 26.7-39% of patients, while myocardial infarction, cardiac complications, and cardiac death occurred in ≤35% troponin-positive patients in four of six studies. Several noncardiac factors were associated with elevated troponin including higher American Society of Anaesthesiologists score, current smoking, reduced mobility/activity level, lower hemoglobin, and living in residential care. Patients with elevated troponin had longer lengths of stay, increased risk for discharge to long-term care facilities, and higher mortality. Increased age, male sex, and higher American Society of Anaesthesiologists score were also associated with mortality. Elevated troponin can be used as a marker of increased morbidity/mortality in elderly hip fracture patients undergoing surgery, as hypothesized, even in the absence of cardiac complications. Perioperative troponin evaluation may be useful for risk stratification, but further studies are needed to clarify risks and benefits of such testing.
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Affiliation(s)
- A Sandhu
- Division of Rheumatology, University of Mississippi School of Medicine, 2500 North State Street, Jackson, MS 39216, USA
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