The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study

Abstract

SummaryHip fracture surgery is associated with a high rate of mortality and morbidity; heart disease is the leading cause and is often unrecognised and inadequately treated. Pre-operative focused transthoracic echocardiography by anaesthetists frequently influences management, but mortality outcome studies have not been performed to date. Mortality over the 12 months after hip fracture surgery, in 64 patients at risk of cardiac disease who received pre-operative echocardiography, was compared with 66 randomised historical controls who did not receive echocardiography. Mortality was lower in the group that received echocardiography over the 30 days (4.7% vs 15.2%, log rank p = 0.047) and 12 months after surgery (17.1% vs 33.3%, log rank p = 0.031). Hazard of death was also reduced with pre-operative echocardiography over 12 months after adjustment for known risk factors (hazard ratio 0.41, 95% CI 0.2-0.85, p = 0.016). Pre-operative echocardiography was not associated with a delay in surgery. These data support a randomised controlled trial to confirm these findings.

Focused ultrasound is the next step in perioperative care

“…17 In a retrospective study, a group based in Melbourne Australia showed that patients admitted with hip fractures who underwent a focused transthoracic ultrasound had lower mortality than a control group. 18 Prospective studies should be undertaken to confirm these findings in similar settings.…”

A reply

“…Canty et al discuss how this information enables proactive management of reduced cardiac function that may result in improved outcomes [4]. This information may also enable judicious use of spinal anaesthesia whether or not significant aortic stenosis is present.…”

“…Our recommendation was based on evidence from the 2001 Report of the National Confidential Enquiry into Perioperative Deaths (NCE-POD) [2], the management and outcome of the 272 hip fracture patients with a previously undiagnosed murmur and echocardiographically proven aortic stenosis admitted from 2001-2005 in our hospital following adoption of the NCEPOD recommendations [3], and the publication by Canty et al which prompted our editorial and which indicated a beneficial effect on 30-day and 1-year mortality for hip fracture patients at risk of cardiac disease who underwent pre-operative TTE compared with those who did not [4].…”

2014 ESC/ESA Guidelines on Non-cardiac Surgery: Cardiovascular Assessment and Management

“…172 In emergency non-cardiac surgery, a pre-operative-focussed TTE examination may significantly alter diagnosis and management. 173 In patients with a poor echocardiographic window, CMR imaging is an excellent method for the evaluation of both cardiac structure and function. 174 The pre-operative levels of natriuretic peptides (BNP or NT proBNP) are strongly correlated to the prognosis of heart failure and to perioperative and post-operative morbidity and mortality.…”