Abstract
Myocardial infarction after hip fracture but before surgical repair is associated with a 30-day mortality as high as 30 % at 1 month. In Florence, since 2011, hip fractures are referred to a multidisciplinary hip fracture team including internal medicine specialists, anesthesiologists, and orthopaedic surgeons. The aim of the present investigation was to evaluate the clinical characteristics of patients with hip fracture who had at hospital admission a significant increase of troponin (>10 times reference levels), the diagnostic and therapeutic strategies adopted, and overall 1-year survival. Protocol at admission included careful clinical evaluation (including bedside echocardiography) in order to stratify surgical risk and schedule surgery and anaesthesiology strategy. 21/1025 patients had preoperative significant troponin increase. In sixteen patients, a diagnosis of NSTEMI was made, five presented with ST elevation. In five patients with NSTEMI considered at very high surgical risk (ASA ≥ 3, severe cognitive and functional impairment), surgery was not performed. None survived at 1 year. Hip surgery was performed in the other 11. Four underwent coronary revascularization after hip surgery. In this group, 1-year survival was 80 %. Four of five ST elevation patients fulfilled criteria for stress cardiomyopathy confirmed by angiography. Hip surgery was performed, and the patients are alive at 1-year follow-up. Close to 2 % of patients with hip fracture are found to have a significant troponin increase before surgery. Three out of four have an NSTEMI diagnosis. In patients undergoing hip surgery, survival at 1 year is close to 80 %. In patients with ST elevation at admission, stress cardiomyopathy should be considered in the differential diagnosis. This clinical condition is associated with a favourable prognosis after hip surgery.
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References
Thiagarajah S, Fenton A, Sivardeen Z, Stanley D (2011) The management and mortality of patients undergoing hip fracture surgery following recent acute myocardial infarction. Acta Orthop Belg 77:626–663
Gupta BP, Huddleston JM, Kirkland LL, Huddleston PM, Larson DR, Rachel E, Gullerud RE, Burton C, Rihal C, Wright RS (2012) Clinical presentation and outcome of perioperative myocardial infarction in very elderly following hip fracture surgery. J Hosp Med 7(9). doi:10.1002/jhm.1967
Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL (2002) The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med 112:702–709
Kristensen SD, Knuuti J, Saraste A, Authors/Task Force Members et al (2014) 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 35:2383–2431
Hietala P, Strandberg M, Strandberg N, Gullichsen E, Airaksinen KE (2013) Peri operative myocardial infarctions are common and often unrecognized in patients undergoing hip fracture surgery. J Trauma Acute Care Surg 74(4):1087–1091
Rostagno C, Cartei A, Buzzi R, Landi F, Gensini GF (2013) Multidisciplinary approach to hip fracture in the elderly: florence experience. Emerg Med 3:148–152
Thygesen K, Alpert JS, Jaffe AS (2012) et al the Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third Univ Def Myocard Infarc Circul 126:2020–2035
Bybee KA, Kara T, Prasad A, Barsness GW, Wright RS, Rihal CS (2004) Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 14:858–865
Mak JCS, Cameron ID, March LY (2010) Evidence-based guidelines for the management of hip fractures in older persons: an update. MJA 192(1):37–41
Shiga T, Wajima Z, Ohe Y (2008) Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth 55:146–154
Moran CG, Wenn RT, Sikand M, Taylor AM (2005) Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 87:483–489
Huddleston JH, Gullerud RG, Smither F, Huddleston, Larson DR, Phy MP, Melton LP, Roger VL (2012) Myocardial infarction following hip fracture repair: a population-based study. J Am Geriatr Soc. 60:2020–2026
Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA (2011) Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med 155(4):226–233. doi:10.7326/0003-4819-155-4-201108160-00006
Alzahrani K, Gandhi R, Davis A, Mahomed N (2010) In-hospital mortality following hip fracture care in southern Ontario. Can J Surg 53(5):294–298
Donohue D, Movahed M (2005) Clinical characteristics, demographics and prognosis of transient left ventricular apical ballooning syndrome. HeartFail Rev 10(4):311–316
Prasad A, Lerman A, Rihal CS (2008) Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 155:408–417
Sharkey SW, Lesser JR, Zenovich AG et al (2005) Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 111(4):472–479
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E (2006) Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 27:1523–1529
Nef HF, Mollmann H, Akashi HY, Hamm CW (2010) Mechanisms of stress (Takotsubo) cardiomyopathy. Nat Rev Cardiol 7:187–193
Watanabe H, Kodama M, Okura Y, Aizawa Y, Tanabe N, Chinushi M, Nakamura Y, Nagai T, Sato M, Okabe M (2005) Impact of earthquakes on takotsubo cardiomyopathy. JAMA 294(3):305–307
Vergez M, Pirracchio R, Mateo J, Payen D, Cholley B (2009) TakoTsubo cardiomyopathy in a patient with multiple trauma. Resuscitation 80:1074–1077
Krpata DM, Barksdale jr. EM (2013) Trauma induced left ventricular apical ballooning syndrome in a 15 year old: a rare case of Tako Tsubo cardiomyopathy. J Pediatr Surg 48:876
Joe BH, Hwang HJ, Park CB, Jin ES, Sohn IS, Cho JM, Kim CJ (2013) Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: a case report. ExpTher Med 6:260–262
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The paper is part of a project financed by a Grant from Italian Health Ministry and Regione Toscana. CUP D11J12000380003.
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All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the Helsinki 1964 declaration and their later amendments or comparable ethical standards. This article does not contain any study with animals performed by any of the author.
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Rostagno, C., Cammilli, A., Di Cristo, A. et al. Acute coronary syndromes with significant troponin increase in patients with hip fracture prior to surgical repair: differential diagnosis and clinical implications. Intern Emerg Med 11, 219–224 (2016). https://doi.org/10.1007/s11739-015-1348-8
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DOI: https://doi.org/10.1007/s11739-015-1348-8