Preoperative Noninvasive Cardiac Testing in Older Adults With Hip Fracture

A Multi-Site Study

Liron Sinvani, MD; Daniel A. Mendelson, MD; Ankita Sharma, DO; Christian N. Nouryan, MA; Joanna S. Fishbein, MPH; Michael G. Qiu, PhD, MD; Roman Zeltser, MD; Amgad N. Makaryus, MD; Gisele P. Wolf-Klein, MD


J Am Geriatr Soc. 2020;68(8):1690-1697. 

In This Article

Abstract and Introduction


Background/Objectives: For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture.

Design: Retrospective chart review.

Setting: Seven hospitals (three tertiary, four community) within a large health system.

Participants: Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married).

Measurements: Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality.

Results: Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8–1.8 days), median LOS was 5.3 days (IQR = 4.2–7.2 days), and in-hospital mortality was 3% (n = 32).

Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE.

Conclusion: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population.


In the United States, approximately 300,000 older adults are hospitalized with acute hip fracture every year, and one-third will die within their first year postfracture.[1–6] With the aging of the population, it is anticipated that by 2040 there will be at least 500,000 yearly hip fracture cases, with projected costs of more than $240 billion in the United States alone.[7] Today, surgical repair is the standard of care, even in the frailest of patients.[8,9] Furthermore, prompt orthopedic intervention, within 48 hours of fracture, has clearly resulted in improved outcomes and reduced mortality.[10–15]

Before surgical repair, a preoperative cardiac assessment must consider the risk-benefit ratio and the possibility of preoperative testing, without compromising the optimal time for intervention. The 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the preoperative cardiovascular risk assessment of patients undergoing "elevated risk" surgery address the role of noninvasive preoperative cardiac testing.[16] As per these guidelines, "For patients at elevated risk of major adverse cardiac event (MACE) and poor (<4 METs [metabolic equivalents]) or unknown functional capacity, the clinician should consult with the patient and perioperative team to determine whether further pharmacologic stress testing will impact patient decision making or perioperative care." In addition, the guidelines also describe that a transthoracic echocardiogram (TTE) may be used to evaluate those with suspected moderate or greater valvular disease, assessment of left ventricle function (in those with symptoms of heart failure or if no evaluation within 1 year), and those with pulmonary hypertension.[16]

In a population where nearly one-half (42.4%) of patients have at least one heart condition and most have significant multimorbidity, the preoperative cardiac risk assessment represents a complex clinical challenge.[17,18] Of concern, preoperative cardiac testing can lead to a delay in surgery that was shown to result in increased morbidity, mortality, and healthcare expenditures.[19–25] We sought to further assess the use of noninvasive preoperative cardiac testing specifically in older adults with acute hip fracture. The objective of our study was to evaluate the association between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing.