Is Bone Repair Surgery Safe After A Heart Stint
J Hosp Med. Author manuscript; available in PMC 2022 Nov i.
Published in final edited form equally:
PMCID: PMC3230699
NIHMSID: NIHMS278593
Impact of Eye Failure on Hip Fracture Outcomes: A Population-Based Report
Michael W. Cullen, MD, Rachel Due east. Gullerud, BS, Dirk R. Larson, MS, Fifty. Joseph Melton, Iii, MD, and Jeanne Chiliad. Huddleston, Medico
Abstract
Groundwork
Hip fracture and center failure are becoming more than prevalent conditions in hospitalized patients. Despite differences in postoperative outcomes from other intermediate risk procedures, guidelines classify hip fracture repair every bit an intermediate risk functioning.
Objective
This population-based study sought to examine the prevalence and incidence of heart failure in hip fracture patients.
Blueprint, Setting, and Patients
We conducted a population-based historical cohort study of i,116 Olmsted County, MN residents undergoing 1,212 hip surgeries from 1988 through 2002. Information were obtained through medical record review. Eye failure was defined past Framingham criteria.
Results
The prevalence of preoperative centre failure in our study population was 27% (327 of 1,212 cases). Those with preoperative middle failure demonstrated longer lengths of stay, were more often discharged to a skilled facility, and had higher inpatient mortality rates. Rates of postoperative centre failure were 6.vii% at seven days and 21.3% at one year. Postoperative center failure was more common among those with preoperative middle failure (Hr 3.0), and those with preoperative heart failure demonstrated higher postoperative bloodshed rates. Men had a higher risk of postoperative mortality compared to women. Overall survival was everyman amid those with both preoperative and postoperative center failure.
Conclusions
Heart failure represents a common and serious perioperative condition in hip fracture patients. Hip fracture patients with and without heart failure behave higher postoperative chance than guidelines may propose. Future work must focus on the perioperative management of hip fracture patients with and without eye failure to mitigate postoperative morbidity.
Keywords: Middle failure, postoperative evaluation and care, cardiovascular run a risk assessment
Introduction
As the population ages, hip fractures and middle failure increase in prevalence.ane , ii Heart failure prevalence is as well increasing in hospitalized patients.3 Indeed, hospitalizations involving heart failure as an active issue tripled in the terminal 30 years.4 Centre failure has been associated with an increased hazard for hip fracture,5 , 6 and previous studies report a 6-twenty% prevalence of preoperative heart failure in hip fracture patients.7 - ten While exacerbation of middle failure increases the mortality risk in patients admitted for hip fractures,viii the incidence of new heart failure, equally well as the preoperative factors that predict postoperative middle failure in this patient population remain unclear.
ACC/AHA perioperative guidelines place orthopedic surgeries, including hip fracture repair, equally "intermediate adventure" procedures.11 Compared to other intermediate take chances operations, however, postoperative outcomes following hip fracture repair differ significantly.12 - sixteen Overall bloodshed in hip fracture patients has been reported at 29% at one twelvemonth,8 with the excess mortality from hip fracture lone at nearly 20%.x , xiii However, the exact factors, that contribute to this excess bloodshed, specially with regard to heart failure, remain unclear.
To examine the preoperative prevalence, subsequent incidence, and predictors of heart failure in patients undergoing hip fracture repair operations, this study used an established, population-based database to compare the postoperative consequences in hip fracture repair patients with and without preexisting heart failure. We hypothesized that preoperative heart failure worsens postoperative outcomes in hip fracture patients.
Methods
Example observation
Following approval by the Institutional Review Boards of Mayo Clinic and the Olmsted Medical Eye, we used the Rochester Epidemiology Project (REP) to identify the patients for this study. The REP is a population-based medical records linkage system that records all diagnoses, surgical procedures, laboratory data, and death information from hospital, emergency room, outpatient, and nursing home care in the community.17
All Olmsted County, Minnesota, residents who sustained a hip fracture and underwent surgical repair from 1988 through 2002 were evaluated. Patients with more than one hip fracture during the study period (96 occurrences) were censored from the data assay at the time of the subsequent hip fracture and then included equally new cases. The consummate enumeration of hip fracture episodes managed in the three Olmsted County hospital facilities (Mayo Clinic's Saint Marys and Rochester Methodist Hospitals and the Olmsted Medical Heart Infirmary) occurred in three phases: First, all hospitalizations with the surgical procedure (ICD9) codes 79.15 (reduction, fracture, femur, closed with internal fixation), 79.25 (reduction, fracture, femur, open up, without internal fixation), 79.35 (reduction, fracture, femur, open with internal fixation), 79.95 (performance, unspecified bone injury, femur), lxxx.05 (arthrotomy for removal of hip prosthesis), 80.15 (arthrotomy, other, hip), fourscore.95 (excision, hip articulation), 81.21 (arthrodesis, hip), 81.40 (repair hip, non elsewhere classified), 81.51 (total hip replacement), 81.52 (fractional hip replacement), and 81.53 (revision hip replacement) were identified. Second, through review of the original inpatient and outpatient medical records, nosotros confirmed that a fracture was associated with the index hospitalization. Finally, radiology reports of each index hospitalization verified the presence and exact anatomical location of each fracture. Of those with fractures on admission x-rays, only patients with a proximal femur (femoral neck or intertrochanteric) fracture as the master indication for the surgery were included in the study. Surgical report or radiographic evidence of hip fracture was available for all patients. Secondary fractures due to a specific pathological lesion (e.g., malignancy) or high-free energy trauma (past convention, motor vehicle accidents or falls from significant heights) were excluded. Only patients who had provided an authorization to review their medical records for inquiry were ultimately included in the study accomplice.eighteen Medical records were search manually, if indicated.
Criteria for heart failure and death
Preoperative heart failure was based on clinical documentation of heart failure in a patient's medical record prior to the time of the hip fracture repair. Postoperative heart failure, including acute exacerbations, was defined according to Framingham criteria.19 Framingham criteria included clinical evidence of increased central venous pressure level, pulmonary edema, an S3 gallop, radiographic pulmonary edema, and response to diuresis. Eye failure was not graded on clinical severity (i.e., New York Centre Association classification). Nosotros did non distinguish between systolic and diastolic heart failure. Bloodshed was defined as death from any cause inside the first year following hip fracture repair. Deaths were identified either through REP resources or the National Death Alphabetize.
Statistical methods
Continuous variables are presented every bit mean ± standard deviation and categorical variables equally number (percent). 2-sample t-tests or Wilcoxon rank sum tests were used to test for significant differences in continuous variables. Chi-Square or Fisher's exact tests were used for categorical variables. Rates of postoperative outcomes were calculated using the Kaplan-Meier method for the overall group and for those with and without preoperative heart failure. A landmark survival bend was used to evaluate postoperative bloodshed amongst patients who experienced heart failure in the first 7 postoperative days versus those who did not. Patients who died or underwent another hip operation within the first 7 postoperative days were excluded from this analysis. Univariate Cox proportional hazards models were used to evaluate the predictors of postoperative middle failure and mortality. Patients who died or experienced a second hip surgery within one year of their first were censored at that fourth dimension. Any subsequent hip fracture repair was treated as a new case. To account for the inclusion of multiple hip fracture repairs for a given patient, the Cox proportional hazards model included a robust variance estimator. This provided an accurate adding of the standard error in the presence of within-subject correlation.20 Statistical tests were two-sided, and p-values were considered significant if less than 0.05. Statistical analyses were performed using SAS (version 9.1.3, SAS Institute, Cary, NC).
Results
From among i,327 potential hip fracture repairs, we excluded 115 cases involving multiple injuries or operations (19), pathological fractures (20), in-hospital fractures (3), or an operation >72 hours after the initial fracture (5). Three patients under 65 years of age were also excluded, as were cases with missing data (nine) or cases managed not-operatively (56). The concluding analysis included 1,212 surgical cases in 1,116 subjects. No subjects were lost to surveillance for 1 year following their hip fracture repair.
Tabular array ane summarizes the baseline characteristics of the written report population. The overall prevalence of preoperative heart failure was 27.0% (327 of one,212). Those with preoperative heart failure were older, heavier, more likely male person and white, and less likely to live independently preoperatively. They were as well more than probable to suffer from preexisting cardiovascular co-morbidities.
Table ane
Baseline characteristics and outcomes amongst Olmsted County, Minnesota, residents undergoing hip fracture repair, 1988-2004, by preoperative centre failure status
| All (N=1212)‡ | HF (N=327)‡ | No HF (N=885)‡ | p-value* | |
|---|---|---|---|---|
| Demographics | ||||
| Mean age (years) (SD) | 84.ii (vii.44) | 85.5 (6.54) | 83.vii (7.70) | 0.0010one |
| Male gender | 237 (xix.vi) | 76 (23.ii) | 161 (18.2) | 0.0491two |
| Mean torso mass index (kg/grand2)† (SD) | 23.iii (4.97) | 24.1 (5.68) | 23.0 (4.65) | 0.0123i |
| White | 1204 (99.3) | 322 (98.5) | 882 (99.7) | 0.03713 |
| Preoperative living situation | ||||
| Nursing facility | 468 (38.6) | 144 (44) | 324 (36.vi) | 0.01842 |
| Dwelling | 744 (61.4) | 183 (56) | 561 (63.4) | |
| Preoperative convalescent condition† | 0.05192 | |||
| Dependent | 149 (12.3) | fifty (15.3) | 99 (xi.2) | |
| Independent | 1061 (87.vii) | 276 (84.7) | 785 (88.8) | |
| Medical history | ||||
| Hypertension | 705 (58.2) | 226 (69.1) | 479 (54.ane) | <0.00012 |
| Diabetes mellitus | 143 (eleven.viii) | 63 (19.3) | fourscore (9) | <0.00012 |
| Cerebrovascular illness | 331 (27.3) | 129 (39.4) | 202 (22.viii) | <0.00012 |
| Peripheral vascular disease | 195 (xvi.1) | lxxx (24.5) | 115 (13) | <0.00012 |
| Coronary artery disease | 464 (38.3) | 237 (72.v) | 227 (25.6) | <0.00012 |
| Atrial fibrillation/flutter | 254 (21) | 133 (40.7) | 121 (13.7) | <0.00012 |
| Consummate heart block | 18 (1.v) | ix (ii.8) | nine (1) | 0.03373 |
| Pacer at fourth dimension of admission | 32 (ii.6) | sixteen (4.9) | 16 (i.viii) | 0.00292 |
| Chronic obstructive pulmonary affliction | 196 (sixteen.2) | 78 (23.ix) | 118 (13.3) | <0.00012 |
| Liver affliction | xv (1.ii) | 7 (2.1) | eight (0.9) | 0.1375three |
| Chronic renal insufficiency¶ | 131 (10.8) | 61 (eighteen.7) | 70 (7.9) | <0.00012 |
| Mean length of hospitalization (days) (SD) | 10.0 (7.57) | 11.1 (8.82) | 9.half dozen (7.01) | 0.00101 |
| Discharge Disposition† | 0.00192 | |||
| Abode | 150 (12.four) | 26 (8.0) | 124 (14.0) | |
| Skilled nursing facility | 1004 (82.nine) | 278 (85.0) | 726 (82.one) | |
| Dead | 57 (iv.7) | 23 (seven.0) | 34 (three.9) |
Table 1 also summarizes the main outcome characteristics of the study population. Those with preoperative heart failure had longer mean lengths of stay (LOS), were more often discharged to a skilled facility, and demonstrated higher inpatient mortality rates.
Table 2 summarizes the outcomes associated with preoperative center failure. The overall rate of postoperative centre failure was half dozen.vii% inside seven postoperative days and 21.3% inside one postoperative year. Postoperative centre failure was significantly more common among those with preoperative heart failure (take chances ratio [HR], 3.0; 95% CI, two.3 to three.9; p<0.001). Among those without preoperative eye failure, rates of postoperative incident centre failure were four.eight% at seven days and fifteen.0% at ane twelvemonth. Compared to patients without preoperative heart failure, those with preoperative heart failure demonstrated higher one year mortality rates and higher rates of postoperative middle failure at seven days and one twelvemonth.
Table two
Association of preoperative eye failure with postoperative outcomes amidst Olmsted Canton, Minnesota, residents undergoing hip fracture repair, 1988-2004
| Preoperative heart failure (subjects) | |||||
|---|---|---|---|---|---|
| Outcome | All (N=1212) | No (North=885) | Yep (N=327) | Take a chance ratio* (95% CI) | p-value |
| Heart failure exacerbation inside 7 postoperative days† | 6.7% (five.4,8.three) | 4.8% (3.v,6.5) | 12.1% (8.7,16.2) | 2.72 (1.72,4.31) | <0.0001 |
| 1-year postoperative centre failure exacerbation# | 21.3% (18.8,23.7) | 15.0% (12.v,17.4) | 39.3% (33.3,44.nine) | 3.00 (2.32,3.87) | <0.0001 |
| 1-year postoperative mortality# | 24.5% (22.0,26.9) | xix.8% (17.1,22.four) | 37.two% (31.6,42.3) | 2.xi (1.67,2.67) | <0.0001 |
| 1-year postoperative mortality or center failure exacerbation# | 36.five% (33.7,39.2) | 29.seven% (26.half-dozen,32.6) | 55.0% (49.3,sixty.2) | 2.28 (1.88,2.76) | <0.0001 |
Figure 1 displays the outcomes to one year of surveillance. Rates of postoperative heart failure and postoperative mortality were consistently higher among those with versus without preoperative heart failure. Figure 2 displays similar data stratified by gender. Postoperative center failure rates did not differ significantly between genders (Hr, ane.0; 95% CI, 0.8 to 1.iv), but postoperative mortality rates were significantly higher among males than females (Hr, i.9; 95% CI, 1.5 to 2.5; p<0.001).
Cumulative incidence of postoperative outcomes among Olmsted County, Minnesota, residents undergoing hip fracture repair, 1988-2004, past preoperative heart failure status
Abbreviations: Heart failure (HF)
Cumulative incidence of postoperative outcomes among Olmsted County, Minnesota, residents undergoing hip fracture repair, 1988-2004, past gender
Abbreviations: Heart failure (HF)
Figure 3 displays survival rates to i year based on the occurrence of incident or recurrent heart failure within the offset 7 postoperative days. Survival rates were lowest among patients with recurrent eye failure in the first seven postoperative days and highest amid those with no preoperative or postoperative heart failure. Subjects with incident centre failure in the outset postoperative week and those with preoperative heart failure who did non suffer a recurrence demonstrated intermediate survival rates (p<0.001 for trend across all four groups).
Landmark survival curve to outcome of survival, past middle failure status*
* Excluded 30 records where the patient died or underwent a 2nd surgery before postoperative twenty-four hour period 7.
Abbreviations: Heart failure (HF)
Discussion
This population-based study plant that centre failure represents a highly prevalent condition in elderly patients undergoing hip fracture repairs. It demonstrates that those with preoperative heart failure typically endure from more cardiovascular comorbidities and carry a higher run a risk of postoperative heart failure and postoperative mortality.
While many studies have focused on the epidemiology of hip fractures,21 population-based data on cardiac complications following hip fracture repair are significantly less mutual. The ACC/AHA preoperative cardiac evaluation guidelines classify orthopedic procedures, including hip fracture repair, equally "intermediate run a risk."11 Consequently, some may assume that all orthopedic patients will have a bloodshed rate less than 5%. Indeed, the 30-24-hour interval postoperative mortality rate published from our institution's Total Joint Registry was 0.vi% post-obit elective total hip arthroplasty.22 However, the present study demonstrates that current ACC/AHA preoperative cardiac evaluation guidelines may non use to the population of delicate patients undergoing hip fracture repair. Particularly among those who experience new middle failure within the first vii days following surgery, outcomes are substantially worse than the ACC/AHA perioperative guidelines may propose.11
Preoperative eye failure has been associated with agin risk for postoperative mortality afterward hip fracture.9 , 10 , 12 However, these studies did not report center failure as a complication of hip fracture repair. A prospective cohort study of ii,448 hip fracture patients at an academic hospital in Peachy Uk found a 5% charge per unit of inpatient heart failure as a postoperative complication.23 The risk ratio for one-year mortality was 11.3 with postoperative heart failure.23 Nonetheless, the British study did non distinguish middle failure from other cardiovascular diseases as a preoperative co-morbidity or stratify the run a risk for postoperative mortality by preoperative centre failure status.23 Our findings add to previous literature by measuring heart failure as a specific complexity of hip fracture repair and examining the association of preoperative eye failure with postoperative heart failure and mortality.
Length of stay after hip fracture repair varies in the literature, but previous piece of work has not clearly associated heart failure with length of hospitalization in the setting of hip fracture repair.24 , 25 Our report found a significantly higher mean length of stay amid those with preoperative centre failure. This adds to previous work by delineating an association between heart failure and increased length of stay afterward hip fracture repair.
Nosotros found a higher rate of postoperative mortality among men compared to women. Rates of postoperative heart failure, however, were more like (Figure 2). Previous studies accept constitute a consistently higher bloodshed rate amongst men vs. women afterward hip fracture.9 , 23 , 25 - 29 Possible explanations for these findings include the overall increased burden of cardiovascular disease amongst men, lower treatment rates of osteoporosis in men,30 and increased susceptibility to other postoperative complications, such every bit infection.25
The findings of this study conduct important clinical implications for the perioperative intendance of hip fracture patients with or at risk for heart failure. They advise that current risk stratification guidelines classifying orthopedic operations as "intermediate hazard" procedures do not reflect the high take chances for morbidity that hip fracture patients face.xi The association of heart failure with adverse outcomes implies the need for heightened surveillance in the perioperative menses, peculiarly with regard to volume status and medication reconciliation. Hip fracture patients and their families must exist counseled most the ramifications of perioperative heart failure, including higher rates of postoperative center failure, longer hospitalizations, and ultimate mortality.
This research carries several limitations and remains subject to biases inherent in retrospective cohort studies. The reported effects of heart failure on outcomes afterwards hip fracture repair may be due to misreckoning from age, functional status, and other co-morbidities. We attempted to minimize sampling bias through consummate enumeration of hip fracture surgeries among Olmsted Canton residents. Completeness of follow-upward (100% at one-year) was possible given the availability of documentation of all inpatient and outpatient medical care in the customs.17
We used objectively defined outcomes to minimize measurement bias. Applicability to a more diverse population may exist express because >95% of the research population was from a single, predominantly white community. Yet, prior studies accept documented that hip fracture incidence rates31 and socioeconomic factors17 in Olmsted County are like to those for other white residents of the U.s.. Middle failure rates were determined clinically according to the Framingham Criteria. However, the Framingham criteria may inappropriately diagnose individuals with heart failure32 and falsely elevate the prevalence of middle failure equally a preoperative comorbidity or postoperative complication.
The statistical analysis included patients multiple times if they underwent subsequent hip fracture repair during the study menstruation. Including these patients may inaccurately inflate event rates or contribute to incorrect estimates of standard error. Notwithstanding, we felt it appropriate to include recurrent hip fracture repair cases in the analysis because they represent a clinically distinct patient from both a medical and functional perspective. Nosotros used a robust variance estimator in the Cox proportional hazards models to provide an accurate calculation of the standard error given the possibility for correlation within subjects.twenty Finally, the proportion of these patients was low (94 of ane,116 unique patients; eight.iv%).
Time to come piece of work must involve further gamble stratification and therapeutic inventions in perioperative hip fracture patients. A more robust assay of heart failure, with differentiation between systolic and diastolic dysfunction may facilitate risk stratification. Assessment of compliance with standard preoperative heart failure medications and the impact of heightened clinical vigilance may enlighten means to improve postoperative outcomes. Studies on risk stratification and therapeutic interventions may and so inform policy regarding length of stay and reimbursement in hip fracture patients.
Conclusion
In summary, our population-based findings reveal that middle failure represents a prevalent and serious comorbidity in patients undergoing hip fracture repair. Clinicians caring for perioperative hip fracture patients must pay item attention to hazard for and implications of new or recurrent center failure.
Acknowledgment
The authors would similar to thank Donna K. Lawson, LPN, Kathy Wolfert, and Cherie Dolliver for their assistance in data collection and management.
Funding and Disclosures
AHA Grant #03-30103N-04. This written report was also fabricated possible by the Rochester Epidemiology Project (Grant # RO1- AG034676 from the National Institute on Aging) and Grant #one-KL2-RR024151 from the National Center for Research Resource (NCRR), a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view, of NCRR or NIH. Information on NCRR is available at http://www.ncrr.nih.gov/. Data on Reengineering the Clinical Research Enterprise is available at http://nihroadmap.nih.gov. All authors had total access to all of the data in the written report and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors take no financial disclosures to written report.
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Is Bone Repair Surgery Safe After A Heart Stint,
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