Where Are We Now?
Ischemic heart disease is a leading cause of perioperative morbidity and mortality following orthopaedic surgery . As a result, reliable assessment protocols for assessing and managing cardiac disease have been developed for patients undergoing elective orthopaedic surgery . 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  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.
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.
How Do We Get There?
Patients with hip fracture require a specialized approach to care . 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  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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