Assessment of cardiovascular risk in patients undergoing total joint alloplasty: the CRASH-JOINT study

Abstract

A b s t r a c tBackground: Risk assessment is of particular importance for patients undergoing surgical interventions. Orthopaedic procedures, especially total joint alloplasty, are major procedures associated with high perioperative risk, as well as one of the highest rates of complications. Aim:The aim of the present study was to establish the prevalence of classical and non-classical cardiovascular risk factors in patients undergoing total hip or knee alloplasty. Methods:The CRASH-JOINT (Cardiovascular Risk Assessment ScHeme in JOINT alloplasty) was a prospective, epidemiological study performed in consecutive patients scheduled for total joint (hip or knee) replacement surgery. Patients enrolled into the study were screened for cardiovascular risk factors and had ambulatory blood pressure performed for the diagnosis of hypertension.Results: The present study enrolled 98 patients. During initial screening eight patients were disqualified from the study and the surgery, in the majority due to the cardiac causes. Sixty-five patients had a hip joint replacement and 25 had knee joint replacement (mean age 63.7 ± 12.2 years, 62.2% female). Fifty (55.6%) patients were diagnosed with arterial hypertension in the past, ten (11.1%) patients had diabetes mellitus, two (2.2%) had a history of myocardial infarction, and family history of cardiovascular disease was present in 24 (26.7%) cases. Mean body mass index (BMI) was 28.0 ± 5.1 kg/m 2 and 39 (43.3%) patients were overweight, while 28 (31.1%) were obese. Patients undergoing hip replacement were significantly younger (61.8 ± 12.6 vs. 68.5 ± 10.0 years; p = 0.02), were more often current smokers (24.6% vs. 4.0%; p = 0.03), had significantly lower BMI (26.8 ± 4.5 vs. 31.2 ± 5.3 kg/m 2 ; p < 0.0001), and were less often obese (18.5% vs. 64.0%; p < 0.0001). There were no significant differences between patients scheduled for primary surgery and reoperation. Conclusions:The study showed that classical cardiovascular risk factors in patients undergoing total hip or knee alloplasty have a higher prevalent than in the general population, which can potentially contribute to the higher risk of development of perioperative complications.

Cardioorthopedics — is it necessary in clinical practice? A study of patients with hip replacement surgery

“…The Cardiovascular Risk Assessment ScHeme in JOINT arthroplasty study (CRASHJOINT) revealed the relatively high prevalence of both classical as well as nonclassical cardiovascular risk factors in patients undergoing total hip or knee replacement, and showed that those fac tors are more common than in the general population [15]. In the study, we found that out of 98 patients, eight patients were excluded from the study and surgery, mainly due to cardiac causes.…”

“…As was mentioned previously [15], the oc currence of cardiac complications after surgery depends on the risk factors of the patient and the type of operation [16]. Each operation triggers a stress response that is initiated by tissue damage, developed with the participation of neuro endocrine factors, and may cause a sympathetic imbalance resulting in myocardial oxygen consumption increase, and an imbalance between prothrombotic factors and fibrinolytic factors.…”

“…The extent of preoperative cardiac evaluation must be tailored to the patient's clinical condition, age, and the urgency of the operation [15]. Preoperative cardiac assessment, as recom mended by the American and European Heart Associations [17,18], enables improved cardiac treatment and reduction of cardiac complications.…”

Pre-operative clinical predictors for cardiology referral prior to total joint arthroplasty: the ‘asymptomatic’ patient

“…There has been no previous research on cardiac referral for the asymptomatic preoperative TJA population in which cardiac disease not yet exhibiting clinical manifestation but capable of contributing to risk of postoperative cardiac complication may exist. Over-referral is unsustainable [ 4 , 22 – 24 ] and may unnecessarily delay surgery [ 25 , 26 ]; however under-referral may lead to missed pre-operative optimisation for asymptomatic patients who otherwise would have benefited, and may contribute to post-operative cardiac complication.…”

Risk assessment according to the SCORE risk chart — from history, through present, to the future

“…These factors include a strong family history of early-onset CVD, milder degrees of impaired glucose regulation, low-density lipoprotein cholesterol, triglycerides, or fibrinogen [5]. Newer studies suggest also the impact of obstructive sleep apnoea, erectile dysfunction, depression and anxiety, air pollution, and periodontal disease as potent cardiovascular risk factors (Table 1) [18][19][20][21][22][23][24]. 15% and more 10-14% 5-9% 3-4% 2% 1% < 1% 9 11 13 16 18 6 8 9 11 13 5 5 6 8 9 3 4 5 5 6 4 4 5 6 8 3 3 4 4 5 2 2 3 3 4 1 1 2 2 3 7 8 10 12 14 5 6 7 8 10 3 4 5 6 7 2 3 3 4 5 5 6 7 8 9 3 4 5 6 7 2 3 3 4 5 2 2 2 3 3 2 2 3 3 4 1 2 2 2 3 1 1 1 2 2 1 1 1 1 1 5 6 8 9 11 4 4 5 6 7 3 3 4 4 5 2 2 3 3 4 3 4 5 5 7 2 3 3 4 5 2 2 2 3 3 1 1 2 2 2 1 2 2 2 3 1 1 1 2 2 1 1 1 1 1 1 1 1 1 0 5 6 7 8 9 3 4 5 5 7 2 3 3 4 5 2 2 2 3 3 3 3 4 4 5 2 2 3 3 4 1 1 2 2 3 1 1 1 1 2 2 2 2 3 3 1 1 2 2 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 0 0 0 0 0 0…”