Background: Preoperative diastolic dysfunction has been proposed as an independent predictor of major adverse cardiac events (MACE) and death after non-cardiac surgery. However, most studies supporting this association have included non-emergent procedures and utilized E/e’ ratio as the predominant echocardiographic variable evaluating diastolic function. Compared to patients undergoing elective surgeries, hip fracture surgery patients are older, and demonstrate a higher comorbidity burden that may increase prevalence of diastolic echocardiographic abnormalities and confer a higher postoperative MACE risk. Furthermore, sufficient echocardiographic evaluation of diastolic function now includes assessment of peak tricuspid regurgitant velocity (TRV) and maximal left atrial volume index (LAVI), in addition to E/e’ ratio. This study aimed to evaluate the relationship between abnormal diastolic echocardiographic parameters and postoperative MACE in patients undergoing hip fracture surgery. We hypothesized that a higher proportion of abnormal diastolic variables (E/e’, TRV and LAVI) would confer an increased risk of postoperative MACE, 1-year and 2-year mortality.
Methods: Retrospective data of 248 consecutive patients undergoing hip fracture repair from April 2016 to June 2021 was collected. Abnormal echocardiographic diastolic parameters were defined as E/e’ ratio > 14, TRV > 2.8 m/sec and LAVI > 34 mL/m2. Patients were divided into two groups based on the number of abnormal parameters: (1) 0 or 1 abnormal and (2) 2 or 3 abnormal. MACE was defined as postoperative myocardial infarction, postoperative heart failure, postoperative pulmonary edema, or death within 30-days of procedure. Chi-squared analysis was used to compare proportions with a p value of < 0.05 considered significant.
Results: 148 patients with complete echocardiographic data were included in the study. Patients in the 2 or 3 group had a higher incidence of preoperative ischemic heart disease, atrial fibrillation, pulmonary hypertension and chronic kidney disease, and were more commonly classified as ASA 4, compared to the 0 or 1 group. Postoperative MACE occurred in 15.5% (n=23) of patients. Overall 1-year and 2-year postoperative mortality rates were 21.6% (n=32) and 30.4% (n=45) respectively. When grouped by abnormal echocardiographic diastolic data, MACE rates were 8.6% in the 0 or 1 group versus 23.9% in the 2 or 3 group (p=0.011). Similarly, 1-year and 2-year mortality was higher in the 2 or 3 group (31.3% vs 13.6%; p=0.009 and 43.3% vs 19.8%; p=0.002).
Conclusions: A higher proportion of abnormal diastolic parameters including E/e’ ratio, TRV and LAVI is associated with an increased risk of post-operative MACE, 1-year and 2-year mortality in patients undergoing hip fracture surgery. Appraisal of these diastolic indices may help identify hip fracture patients at highest risk for MACE and open avenues for better preoperative optimization and postoperative management.
