The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture

Mutlu, Harun; Bilgili, Fuat; Mutlu, Serhat; Karaman, Özgür; Çakal, Beytullah; Özkaya, Ufuk

doi:10.3233/bmr-150595

Cited by 26 publications

(33 citation statements)

References 21 publications

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“…Nevertheless, delaying surgery with a cardiac consultation that is not recommended or contributing could lead to worse outcome. Cardiac consultations increase delay to surgery, which is confirmed by several other studies [7,20]. However, in this study, no significant differences in postoperative complications in the overscreening group vs correctly screened patients were found, which may be due to a small sample size.…”

Section: Discussionsupporting

confidence: 84%

Cardiac overscreening hip fracture patients

Smeets

Wunnik

Poeze

et al. 2019

Arch Orthop Trauma Surg

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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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Section: Discussionsupporting

confidence: 84%

Cardiac overscreening hip fracture patients

Smeets

Wunnik

Poeze

et al. 2019

Arch Orthop Trauma Surg

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“…reviewed the effect of preoperative non-invasive cardiac test on hip fracture patients and found that further cardiac test led to a significant delay to surgery [16]. Cluett et al compared the outcomes between the patients with cardiac evaluation besides electrocardiograph (22 patients) and the control group with only electrocardiograph (86 patients), which found the patients with further cardiac test had obvious surgery delay [17].…”

Section: Discussionmentioning

confidence: 99%

Clinical guidelines reduce unnecessary preoperative echocardiograph in elderly hip fracture patients

Chen¹,

Ma²,

Li³

et al. 2020

Preprint

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Background The American College of Cardiology (ACC) and the American Heart Association (AHA) have set up guidelines for preoperative usage of transthoracic echocardiograph (TTE) in case of non-cardiac surgery. Unnecessary TTE would increase hospital cost and delay surgery. Therefore, we aimed to analyze whether the TTE before hip fracture surgery was in accordance with guidelines and what the effects were on outcome. Methods 281 elderly patients who had surgery for an isolated hip fracture were involved. The preoperative TTE test and adherence to the guideline were analyzed. TTE reports were reviewed for the presence of major cardiac abnormality with potentiality to change perioperative management, including left ventricular systolic or diastolic dysfunction, pericardial effusion, moderate or severe valvular disease, and pulmonary hypertension. Primary outcome was time to surgery (TTS), length of hospital stay (LLS), postoperative complications. Secondary outcome was sensitivity and specificity of accordance with the guideline for identifying which patients would have TTE that demonstrated major cardiac abnormality. Results Of the 281 patients included, 174 patients (61.9%) received the TTE, whereas 107 patients did not. Only 71 of the 174 patients (40.8%) with TTE met the guidelines. Among the 202 patients who did not meet the guidelines (103 with TTE and 99 without TTE), those who received a preoperative TTE had a longer TTS (4.24 vs. 2.10 days, P = 0.000) and LOS (10.44 vs. 7.72 days, P=0.000). There were no differences in postoperative complication, the sensitivity and specificity of guidelines as the screening tool to identify patients with major cardiac abnormality was 86.7% and 68.7%. Conclusion Preoperative TTE is frequently overused out of guidelines and lead to unnecessary surgery delay while not reducing the rate of postoperative complications. Stricter adherence to guidelines should be recommended, as it would help decrease unnecessary test.

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“…Ricci et al [23] demonstrated that preoperative cardiac testing (DTS, echocardiography, and cardiac catheterization) did not change the management of perioperative orthopedic surgery or medical therapy in elderly patients with hip fractures but did incur a huge cost of over $47 million annually in the USA; patients undergoing cardiac testing had a delay to surgery on average 3.3 days, which was 1.4 days greater than those who did not. Multiple studies have also demonstrated that preoperative cardiac testing with echocardiography delays surgery without a significant change in preoperative cardiac medications or anesthesia [14,[24][25][26]. In addition, the cost of a thallium test is 261.22 dollars at our institution.…”

Section: Discussionmentioning

confidence: 99%

Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty?

Liao

Tan

et al. 2020

J Orthop Surg Res

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Background This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty. Methods Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables. Results The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002). Discussion Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery. Level of evidence Prognostic level III

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The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture

Abstract: Unnecessary cardiac tests in elderly patients with hip fracture led to a delay in their surgery, yet did not change their cardiac treatment plan. This delay in obtaining hip fracture surgery increases complication rates, hospitalization duration, and costs.

Cited by 26 publications

References 21 publications

Cardiac overscreening hip fracture patients

Cardiac overscreening hip fracture patients

Clinical guidelines reduce unnecessary preoperative echocardiograph in elderly hip fracture patients

Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty?

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