Sat., 10/20/07 Geriatrics/Injury Prevention, Paper #49, 9:25 am OTA-2007
Cardiac Stress Testing Has Limited Value Prior to Hip Fracture Surgery
S. Andrew Sems, MD (n); Erik C. Summers, MD (n); Traci L. Jurrens, MD (n);
Mayo Clinic, Rochester, Minnesota, USA
Purpose: Patients sustaining hip fractures often have multiple medical comorbidities, and medical evaluation for cardiac clearance is frequently required prior to any planned surgical intervention. Dobutamine stress echocardiograms and sestamibi scans are occasionally performed as a part of the preoperative cardiac evaluation. The purpose of this study was to determine the frequency of preoperative cardiac stress testing, the frequency of cardiac intervention before hip fracture surgery, the impact these tests had on delaying fracture fixation, and the perioperative mortality in the hip fracture population in our institution.
Methods: A retrospective case-controlled series of all patients who had proximal femur fractures (OTA 31A and B) between 2001 and 2006 was performed. Patients who underwent dobutamine stress echocardiograms (DSE) or sestamibi scans after sustaining hip fractures but prior to hip fracture fixation were identified. We identified 1048 hip fractures in 1011 patients, with 55 patients undergoing preoperative cardiac stress testing. Of the patients receiving stress testing prior to surgery, there were 40 females and 15 males, with an average age of 81.5 years (range, 65-98). The control group consisted of the remaining 956 patients over 65 years of age with hip fractures who did not have preoperative cardiac stress testing. There were 690 females and 276 males with an average age of 83.8 years (range, 65-105) in the control group.
Results: The cardiac intervention rate following stress testing was 1.8% (1/55). One patient who had a DSE underwent subsequent coronary artery bypass grafting prior to hip fracture fixation, and died within 2 months. No patients with sestamibi scans underwent cardiac intervention. The stress tests were positive for ischemia in 13 patients (12 DSE and 1 sestamibi). The overall mortality rates were 9.2% at 30 days, 15.4% at 90 days, and 30.7% at 1 year. There was no statistically significant difference in 30-day, 90-day, or 1-year mortality between patients with and without preoperative stress testing. The average time from presentation to hip fracture surgery was significantly longer for the stress test group at 2.79 days as compared to the control group at 1.33 days (P <0.0001).
Conclusion and Significance: Preoperative DSE and sestamibi scans resulted in very low rates of cardiac intervention in patients with hip fractures waiting for surgery. Patients who necessitated preoperative cardiac stress testing waited more than a full day longer on average for surgery than patients who did not undergo stress testing. While these tests may be appropriate as a preoperative screening tool for elective orthopaedic procedures, their utility in the hip fracture patient population is limited. Based on almost no cardiac interventions from 2001 to 2006 in the hip fracture population at our institution, the risks of delay while awaiting stress testing in the hip fracture population may outweigh any potential benefit from these studies.
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