Background: In 2014, the ACC/AHA released guidelines regarding indications for preoperative transthoracic echocardiogram (pre-op TTE) in patients undergoing noncardiac surgery. Studies indicate that the ordering of pre-op TTE in noncardiac surgery is not consistent with the ACC/AHA guidelines. Some studies suggest the pre-op TTE have a significant impact on management, while others have demonstrated low cardiac intervention rates. Our primary objectives are to identify if pre-op TTEs in acute fragility hip fracture repair are ordered according to ACC/AHA guidelines and if they changed management or outcomes.
Methods: We conducted a retrospective chart audit on patients admitted for acute hip fractures from 2012-2016. Information gathered from patient charts included patient characteristics; comorbidities; indications for TTE; perioperative management changes; post-op cardiopulmonary complications; time to surgery (TTS); length of stay (LOS) and 1-year mortality.
Results: 402 patient charts were reviewed, 265 (66%) were female, 138 (34%) were male, with a mean age of 80.4 (Table 1). A total of 45 (11%) patients received pre-op TTE; indications included history of CHF (11), valve disease (9), new murmur (10), previous MI (6), syncope (5), atrial fibrillation (2) and dyspnea (1). Reason for pre-op TTE was uncertain in 1 chart reviewed. A total of 87 (22%) patients had indications for pre-op TTE per ACC/AHA guidelines. Of these, only 42 (48%) patients received pre-op TTE. TTE findings in these patients were associated with a change to anesthesia management in 25 (55%), and a total of 5 (12%) suffered a major adverse cardiac event (MACE). A total of 45 (52%) patients who had indications for pre-op TTE did not receive a TTE, 16 (35%) were associated with changes to standard anesthesia, and 4 (9%) suffered a MACE. These findings are summarized in Table 2. A total of 42 (10%) patients had a post-operative TTE. Of these 14 (33%) had indications for pre-op TTE, 8 (19%) were ordered prior to surgery. In patients with indications for TTE, those who received pre-op TTE had a 1-year mortality of 33%, average TTS of 16.1hrs, and average LOS of 6.8 days, while those who did not receive pre-op TTE had 1-year mortality of 16%, average TTS of 10.5hrs and average LOS of 5.5 days.
Conclusions: The ordering of pre-op TTE in the setting of acute hip fracture surgery is inconsistent with ACC/AHA guidelines. Of patients with indications for pre-op TTE, those who received pre-op TTE had more changes to standard anesthetic management, longer time to surgery and length of stay, and greater 1-year mortality. This might suggest that this population was a higher risk group, however, their RCRI scores were lower, and ASA scores were similar to the patients who had ACC/AHA indications but did not receive pre-op TTE. It is possible that pre-op TTEs delayed surgery or adjusted treatment that actually produced poorer outcomes. Alternatively, there may be more clinical decision making than is captured by the ACC/AHA guidelines.
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