Abstract
Cardiovascular complications in patients undergoing non-cardiac surgery are associated with longer hospital stays and higher in-hospital mortality. The aim of this study was to assess the incidence of in-hospital myocardial infarction and/or myocardial injury in patients undergoing hip fracture surgery and their association with mortality. Moreover, we evaluated the prognostic value of troponin increase stratified on the basis of peak troponin value. The electronic records of 1970 consecutive hip fracture patients were reviewed. Patients <70 years, those with myocardial infarction <30 days, and those with sepsis or active cancer were excluded from the study. Troponin and ECG were obtained at admission and then at 12, 24, and 48 h after surgery. Echocardiography was made before and within 48 h after surgery. Myocardial injury was defined by peak troponin I levels > 99th percentile. A total of 1854 patients were included. An elevated troponin concentration was observed in 754 (40.7%) patients in the study population. Evidence of myocardial ischemia, fulfilling diagnosis of myocardial infarction, was found in 433 (57%). ECG and echo abnormalities were more frequent in patients with higher troponin values; however, mortality did not differ between patients with and without evidence of ischemia. Peak troponin was between 0.1 and 1 µg/L in 593 (30.3%). A total of 191 (10%) had peak troponin I ≥ 1 µg/L, and 98 died in hospital (5%). Mortality was significantly higher in both groups with troponin increase (HR = 1.37, 95% CI 1.1–1.7, p < 0.001 for peak troponin I between 0.1 and 1 µg/L; HR = 2.28, 95% CI 1.72–3.02, p < 0.0001 for peak troponin ≥1 µg/L) in comparison to patients without myocardial injury. Male gender, history of coronary heart disease, heart failure, and chronic kidney disease were also associated with in-hospital mortality. Myocardial injury/infarction is associated with increased mortality after hip fracture surgery. Elevated troponin values, but not ischemic changes, are related to early worse outcome.
Highlights
The incidence of perioperative myocardial infarction (MI) in patients with non-cardiac surgery has been reported between 6% and 36% according to the diagnostic criteria used in different studies [1,2,3]
Patients undergoing hip surgery have a high incidence of myocardial injury, and troponin increase is associated with poor prognosis [8,9,10]
Incidence of perioperative MI/myocardial injury after hip surgery was about 40%, and a definite diagnosis of myocardial infarction according to the fourth universal definition was made in 23% of patients
Summary
The incidence of perioperative myocardial infarction (MI) in patients with non-cardiac surgery has been reported between 6% and 36% according to the diagnostic criteria used in different studies [1,2,3]. Even small troponin increases (above upper 99th percentile of normal reference population) are associated with prolonged hospitalization and increased short- and long-term mortality [6,7]. Several clinical conditions, such as pulmonary embolism, sepsis, renal failure, and acute respiratory failure, may cause troponin to increase; these conditions may be ruled out on clinical basis. Patients undergoing hip surgery are followed by a multidisciplinary group [11] This organization allows us to routinely perform post-operative ECG and echocardiogram; troponin changes can be related with clinical and/or objective evidence of myocardial ischemia, allowing for a distinction to be made between MI and myocardial injury. We evaluated the relation between different degrees of peak troponin values and early outcome
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