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CORRInsights®: Does N-terminal Pro-brain Type Natriuretic Peptide Predict Cardiac Complications After Hip Fracture Surgery?

Cornell, Charles N. MD1,a

Clinical Orthopaedics and Related Research®: June 2017 - Volume 475 - Issue 6 - p 1737–1739
doi: 10.1007/s11999-017-5262-4
CORR Insights
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1The Hospital for Special Surgery, 535 East 70th Street, 10021, New York, NY, USA

ae-mail; cornellc@hss.edu

Received January 15, 2017/Accepted January 24, 2017; previously published online January 31, 2017

This CORR Insights®is a commentary on the article “Does N-terminal Pro-brain Type Natriuretic Peptide Predict Cardiac Complications After Hip Fracture Surgery?” by Ushirozako and colleagues available at: DOI: 10.1007/s11999-017-5245-5

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-017-5245-5

This comment refers to the article available at: http://dx.doi.org/10.1007/s11999-017-5245-5.

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Where Are We Now?

Ischemic heart disease is a leading cause of perioperative morbidity and mortality following orthopaedic surgery [10]. As a result, reliable assessment protocols for assessing and managing cardiac disease have been developed for patients undergoing elective orthopaedic surgery [5]. While these same tools can be used for patients in whom urgent surgery is being considered—such as older patients with hip fractures—it would be advantageous to these more-fragile patients if we could make these protocols more generalizable, more efficient, more accurate, and less expensive

In the current study, Ushirozako and his colleagues suggest that N-terminal Pro-brain Type Natriuretic Peptide (NT-proBNP) may be a useful laboratory blood test that can identify patients with hip fracture at risk of cardiac complications. NT-proBNP is a peptide released from cardiac muscle during periods of ventricular wall stress, typically resulting from myocardial ischemia or congestive heart failure. Though a serum level above 125 pg/ml is abnormal, the authors found that levels above 600 pg/ml are strongly associated with cardiac complications and death following hip fracture surgery. NT-proBNP has been studied in a variety of surgical settings including hip fracture [7] with similar conclusions.

Not surprisingly, all patients who tested above the cut-off level of 600 pg/ml had symptomatic cardiac disease that was also identified by routine history, physical examination, lab testing, and assignment of an ASA score. Though these tests may have real value if it identifies asymptomatic patients at risk, these patients are at low risk for cardiac events and do not benefit from enhanced testing, particularly if it delays scheduling of surgical repair [4, 9]. Still, NT-proBNP may have an important role for the patient whose past history or reliable exam cannot be obtained.

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Where Do We Need To Go?

This study confirms that patients with hip fracture who are at an increased risk of cardiac complications and death can be reliably identified during the preoperative assessment. The challenge, however, is determining what can be done with that knowledge. Currently, there is little evidence that surgical delay beyond 48 hours improves results. Although many of the interventions that are cardio-protective—such as administration of beta-blockers or aspirin—can reduce the risk of perioperative cardiac events, these same interventions can also produce equally harmful noncardiac complications resulting in greater morbidity and mortality [3, 8] such as hypotension leading to stroke and potentially death. Determining how perioperative interventions may aid without harming patients with hip fracture remains elusive.

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How Do We Get There?

Patients with hip fracture require a specialized approach to care [1]. Comanaged care has become the standard of care for this patient population with evidence that this approach improves outcomes and reduces cost [2, 6]. Now is the time to implement multicenter trials similar to the POISE trial model [8] within the hip fracture population. Studies of interventions to improve outcome in hip fracture patients are often inconclusive because aggressive intervention is usually practiced in this high risk population. There is bias in the approach to care. Therefore, it is typical that interventions in this population don't alter the incidence of complications or survival because every effort to avoid risk is already in practice. Efforts to reduce cardiac risk may not be conclusive because risk cannot be reduced below current levels. The focus of studies should therefore not only be on 30-day risk, but on longer-term survival with careful measurement of functional ambulation and levels of pain. Since the true goal is returning the elderly patient to their premorbid condition, then outcomes that assess return to quality-of-life are most valid.

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References

1. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly: Evidence-based clinical practice guideline. Available at: http://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed January 17, 2017.
2. Bukata S, DiGiovanni BF, Friedman SM, Hoyen H, Kates A, Kates SL, Mendelson DA, Sema FH, Siber FE, Tyler WK. A guide to improving the care of patients with fragility fractures. Geriatr Orthop Surg Rehabil. 2011;2:5-37 10.1177/21514585103975043597301.
3. Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, Villar JC, Sigamani A, Biccard BM, Meyhoff CS, Parlow JL, Guyatt G, Robinson A, Garg AX, Rodseth RN, Botto F, Lurati Buse G, Xavier D, Chan MT, Tiboni M, Cook D, Kumar PA, Forget P, Malaga G, Fleischmann E, Amir M, Eikelboom J, Mizera R, Torres D, Wang CY, VanHelder T, Paniagua P, Berwanger O, Srinathan S, Graham M, Pasin L, Le Manach Y, Gao P, Pogue J, Whitlock R, Lamy A, Kearon C, Baigent C, Chow C, Pettit S, Chrolavicius S. Yusuf S; POISE-2 Investigators. Aspirin in patients undergoing non-cardiac surgery. N Eng. J Med. 2014;370:1494-503.
4. Jetto P, Kakwani R, Junejo S, Talkhani I, Dixon P. Pre-operative echocardigram in hip fracture patients with cardiac murmur- an audit. J Orthop Surg Res. 2011;6:49 10.1186/1749-799X-6-49.
5. Levin L. Mackenzie CR, Cornell CN, Memtsoudis SG. Perioperative care of the orthopedic patient with cardiac disease. Perioperative care of the orthopedic patient 2014;New York, NYSpringer125-138.
6. Mears SC, Kates SL. A guide to improving the care of patients with fragility fractures edition 2. Geriatr Orthop Surg Rehabil. 2015;6:58-120.
7. Nordling P, Kiviniemi T, Strandberg M, Strandberg N, Airaksinen J. Predicting the outcome of hip fracture patients by using N-terminal fragment of pro-B-type natriuretic peptide. BMJ Open. 2016;6:e009416 10.1136/bmjopen-2015-0094164769421.
8. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of metoprolol succinate in patients undergoing non-cardiac surgery (POISE Trial). Lancet. 2008;371:1839-1847.
9. Smith T, Pelpola K, Bali M, Ong A, Myint PK. Pre-op indicators for mortality following hip fracture surgery: A systematic review and meta-analysis. Age Ageing. 2014;43:464-471 10.1093/ageing/afu065.
10. Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery; European Society of Cardiology (ESC), Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe G, Vermassen F Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30:2769-2812.
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