Preoperative cardiac evaluation of geriatric patients with hip fracture

BACKGROUND: The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed guidelines for perioperative assessment of patients in case of non-cardiac surgery. The aim of this study was to investigate if the preoperative cardiac evaluation of geriatric patients with hip fracture was in accordance with these guidelines and what the effects were on outcome. METHODS: In a retrospective study 388 patients with hip fracture treated in the department of Trauma surgery of the Maastricht University Medical Centre in the Netherlands were included. All patients were treated between 2003 and 2006 and had at least two year follow-up. The preoperative cardiac screening was analysed with respect to content and to which level this followed the ACC/AHA guidelines. These guidelines were used to classify cardiac risk into low, intermediate and high risk. This was related to the outcome measurements delay to surgery, perioperative complications and mortality. RESULTS: According to the ACC/AHA guidelines 82% of patients received correct preoperative cardiac screening in the low vs. 46% in the intermediate and 86% in the high risk group. The most frequent reason for incorrect preoperative cardiac screening was overscreening (>95%). The delay to surgery increased by 9.9h in the case of overscreening (p=0.03). A previous cardiac history was a significant risk factor for early mortality. Delay of >48 h was associated with more cardiovascular complications and mortality both on univariate and multivariate analysis. CONCLUSION: Preoperative cardiac screening is frequently unnecessary after hip fracture, especially in patients with intermediate risk predictors and increases the delay to surgery. Delay of >48 h was associated with more cardiovascular complications and mortality postoperatively. The implementation of the ACC/AHA guidelines may prevent unnecessary cardiac consultations which reduces preoperative resources, delay to surgery and possibly decreases postoperative complications