Older Patients With Hip Fractures at Increased Risk for Heart Failure

Terry Hartnett

April 13, 2010

April 13, 2010 (Washington, DC) — Patients older than 75 years who need surgery to repair a hip fracture have a critically higher incidence of congestive heart failure and a significantly worse outcome than their counterparts without hip fractures, researchers reported here at Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting.

Warning signs such as arrhythmia should be monitored closely by hospitalists and other healthcare providers to prevent poor patient outcomes, Michael Cullen, MD, chief medical resident at the Mayo Clinic in Rochester, Minnesota, advised meeting attendees.

Dr. Cullen presented the findings of a population-based study he and his colleagues conducted here during a poster session.

"Elderly patients who have a hip fracture have a much higher risk for postoperative heart failure than younger patients," Dr. Cullen told Medscape Internal Medicine during an interview at the meeting.

"Patients who have had a cardiac event before the hip fracture surgery are at increased risk of having a heart failure event after surgery," said Dr. Cullen. Use of medications to treat preoperative heart failure, arrhythmias, and other cardiac conditions also lead to higher rates of heart failure following hip surgery.

"These patients can decompensate rapidly and therefore need to be monitored closely," said Dr. Cullen. "They have so many factors against them — comorbidities, the stress of the injury itself, and the stress of surgery; these all add up to create a serious risk to these patients."

In the study, Dr. Cullen and his colleagues sought to determine what factors led to a higher risk for heart failure after hip fracture, particularly in the 7 days after the operation. Addressing this risk is critical, he said, because a heart failure event can severely limit postoperative recovery and rehabilitation, and lead to longer hospital stays and poor overall outcomes.

Dr. Cullen and his colleagues at the Mayo Clinic reviewed the medical records of all patients in Olmsted County, Minnesota, who were older than 65 years and who had undergone hip repair surgery during a 4-year period. They followed 1212 patients postoperatively for 1 year. If a patient had a second hip operation during the follow-up period, it was counted as a separate case study.

The study found that the cumulative rate of postoperative heart failure was 21.3% (95% confidence interval [CI], 18.8% - 23.7%). Rates of postoperative heart failure were significantly higher among those with preoperative heart failure (hazard ratio, 3.0; 95% CI, 2.3% - 3.9%; P < .001). Risk for inpatient mortality was much higher in those who developed early postoperative heart failure (odds ratio, 4.7; 95% CI, 2.4% - 9.0%; P < .001).

The investigators looked at a number of possible predictors of heart failure and compared them with events that occurred after surgery. The highest number of postoperative cardiac events was for patients older than 75 years (229 events), followed by those with hypertension (157 events), angina (108 events), atrial fibrillation (94 events), a previous heart attack (86 events), and cerebrovascular disease (85 events). Patients older than 85 years had 134 events.

The medications given before surgery for cardiac conditions that led to the highest number of incidents were aspirin (89 events), loop diuretics (84 events), angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (69 events), calcium channel blockers (54 events), and digoxin (54 events).

The factors that led to a low incidence of heart failure postoperatively included coronary revascularization done 6 months to 5 years before the operation, liver disease, complete heart block, pacemaker, and the use of thiazide diuretics.

Dr. Cullen said that risk factors for heart failure, particularly those that occur before the need for hip fracture surgery, must be given closer attention and monitoring both before and after surgery.

The results of this study point to the growing need for the comanagement of surgical patients between the surgeon (in this case, the orthopaedist) and the hospitalist, said Janet Nagamine, MD, a member of the SHM Board, and a hospitalist at Kaiser Permanente Medical Group in Santa Clara, California.

Dr. Nagamine told Medscape Internal Medicine that SHM has developed a new initiative for surgical comanagement. The hospitalist sees the patient pre-, peri-, and postoperatively, she said.

Dr. Nagamine served as head of the SHM quality and safety committee for 7 years, and said this study is a classic example of how quality and safety can be improved with a comanagement strategy.

The study did not receive commercial support. Dr. Cullen and Dr. Nagamine have disclosed no relevant financial relationships.

Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting. Abstract 41. Presented April 9, 2010.