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Published on: August 17, 2017
Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy
Flavia K Borges1,2,3, Ernesto Guerra-Farfan4,5, Mohit Bhandari6
1Population Health Research Institute, Hamilton, Ontario, Canada.
Insights
Accelerated surgery significantly reduced mortality in hip fracture patients with myocardial injury. This approach offers a better prognosis compared to standard care for this high-risk group.
Area of Science:
- Cardiology
- Orthopedics
- Geriatric Medicine
Background:
- Myocardial injury is common and associated with poor outcomes in hip fracture patients.
- Prompt surgical intervention may mitigate risks by reducing physiological stress.
Purpose of the Study:
- To evaluate if accelerated surgery improves 90-day survival in hip fracture patients with elevated cardiac biomarkers.
- To compare accelerated surgery versus standard care for this patient population.
Main Methods:
- Post-hoc analysis of the HIP ATTACK randomized controlled trial (RCT).
- Included 1392 patients with troponin measurements at hospital arrival.
- Primary outcome: all-cause mortality at 90 days; secondary outcome: composite of mortality, MI, stroke, heart failure.
Main Results:
- 23% of patients (322/1392) had elevated troponin.
- Accelerated surgery group: median surgery time 6 hours vs. 29 hours for standard care.
- Lower 90-day mortality in accelerated surgery group (10% vs. 23%; HR=0.43).
Conclusions:
- Myocardial injury affects approximately 1 in 5 hip fracture patients.
- Accelerated surgery demonstrated a reduced mortality risk compared to standard care.
- Findings suggest potential benefit, warranting further confirmation.
Background:
Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival.
Methods:
The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization.
Results:
Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]).
Conclusions:
One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed.
Level Of Evidence:
Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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