HIP ATTACK data show elevated troponin in 1 in 5 hip fracture patients, reports a new study in JBJS.
For hip fracture patients with elevated troponin levels, accelerated surgery may reduce the risk of death or major complications, according to clinical trial data reported in JBJS. Access the study at JBJS.org, along with a video abstract of the findings:
Myocardial Injury in Patients with Hip Fracture. A HIP ATTACK Randomized Trial Substudy
“Myocardial injury in patients with a hip fracture is important because it is associated with a poor prognosis and a risk of premature death,” according to the report by Flavia K. Borges, scientist at the Population Health Research Institute (PHRI), and colleagues. PHRI is a joint institute of McMaster University and Hamilton Health Sciences.
Based on the new analysis of randomized trial data, “accelerated surgery has the potential to improve mortality rates and major cardiovascular outcomes compared with standard care” for patients with myocardial injury, according to the study authors.
High rate of myocardial injury in patients with hip fracture
In the international PHRI HIP ATTACK trial, patients with a hip fracture were randomly assigned to accelerated surgery versus standard care. The full analysis of 2,970 patients found no significant difference in the primary outcome of 90-day all-cause mortality or in a composite secondary outcome including death or major perioperative vascular complications.
The new post hoc analysis focused on 1,392 patients who underwent cardiac biomarker/enzyme measurement—mainly troponin—on arrival at the hospital. Rates of elevated troponin were assessed, and mortality and complication rates were compared between groups.
Of the 1,392 patients, 23% had elevated troponin levels, indicating myocardial injury (i.e., heart injury). Patients with elevated troponin were somewhat older, with a mean age of 82 years compared with 78 years among patients with normal troponin levels, and had a higher baseline risk of complications, reflecting increased comorbidity. Patients with myocardial injury were more likely to be male and more likely to have hypertension, along with higher creatinine and lower hemoglobin level. With or without myocardial injury, the median time from hip fracture diagnosis to surgery was 6 hours for patients assigned to accelerated surgery versus 29 hours in the standard care group.
Patients with elevated troponin ‘could benefit from expedited surgical care’
Among patients with elevated troponin levels, 90-day overall mortality was 10% for those assigned to accelerated surgery compared to 23% for those assigned to standard care. The survival advantage remained significant on adjusted analysis, with a hazard ratio of 0.43.
Accelerated surgery was also associated with reduction in the composite outcome of mortality and complications: 14% for accelerated care versus 30% for standard care. For patients without myocardial injury, outcomes were not significantly different with accelerated versus standard care.
“Most likely the myocardial injury is a consequence of the physiologic stress induced by the hip fracture and is a marker of a poor cardiac reserve,” the researchers write. “Our results suggest that patients presenting with myocardial injury are not tolerating the additional cardiac stress associated with a hip fracture and could benefit from expedited surgical care.”
Since these patients may not have typical symptoms of cardiac ischemia, they may go unrecognized without troponin testing. While emphasizing the need for confirmatory trials, Dr. Borges and coauthors conclude, “Based on a strong biologic rationale and encouraging preliminary data, expedited surgery for patients with a hip fracture and myocardial injury at hospital presentation has the potential to be a paradigm change in the management of hip fracture patients.”
In an accompanying editorial, Dr. Vincent D. Pellegrini Jr. reflects on the potential implications of the study, while also echoing the need for confirmatory trials. “Ironically, those whom we view to be at greatest risk and in whom we are currently most cautious and hesitant to proceed with accelerated surgery for their hip fracture may stand the most to gain,” he writes.
Further perspective is offered in a new commentary by Dr. Charles Cornell, who notes that the study demonstrates that the preoperative period following hip fracture “is a critical period that definitely impacts morbidity and mortality. These revelations need to be acted upon.”
Access the study and video abstract at JBJS.org: Myocardial Injury in Patients with Hip Fracture. A HIP ATTACK Randomized Trial Substudy
Read the editorial by Vincent D. Pellegrini Jr., MD: Adding (Surgical) Insult to (Myocardial) Injury After Hip Fracture
Read the commentary by Charles Cornell, MD: Patients Presenting with Acute Myocardial Injury with Hip Fracture Have Greater Survival with Rapid Surgical Care
Great study – we learn more about hip fracture care the more attention we pay to patient outcomes