Impact of Perioperative Cardiac Assessment Guidelines on Management of Orthopedic Surgery Patients

Abstract

Purpose The study assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) preoperative cardiac assessment guidelines impact patient management and predict major cardiac events in patients undergoing orthopedic surgery. Subjects and methods We conducted a retrospective review of 338 consecutive orthopedic preoperative evaluations performed by internal medicine consultants. Major cardiac events were defined as myocardial infarction, congestive heart failure, and sudden cardiac death. Results Major cardiac events occurred in 5.7% of patients. Patients with minor or absent ACC/AHA clinical risk predictors were less likely to have major cardiac events ( P = .007). More than half (51%) of patients meeting ACC/AHA indications for noninvasive cardiac tests did not receive them. However, most (69%) major cardiac events occurred in patients not meeting criteria for cardiac testing. Abnormal noninvasive cardiac testing results did not alter medication recommendations and only resulted in coronary revascularization in 0.6% of patients. Only 3% of patients with abnormal noninvasive cardiac testing results had major cardiac events. Patients with abnormal cardiac test results were more likely to have recommendations for perioperative beta-blockade ( P <.01). Patients aged more than 70 years (odds ratio 5.0; 95% confidence interval, 1.32-19.28) and patients undergoing hip surgery (odds ratio 7.5, 95% confidence interval, 1.02-54.55) were more likely to have major cardiac events. Major cardiac events occurred in 12% of urgent and 4% of elective procedures ( P = .009). Conclusions The ACC/AHA guidelines accurately predict cardiac risk in orthopedic surgery. Abnormal noninvasive cardiac test results rarely affected preoperative recommendations, but improved compliance with beta-blocker therapy. Advanced age, urgent procedures, and hip surgery were associated with increased risk of major cardiac events.