How do preoperative echocardiograms in geriatric hip fracture patients affect care? A matched cohort study

Hip fractures are among the most common injuries sustained by geriatric patients. Expedient surgery is advocated, but striking the balance of early surgical intervention and medical optimization remains a challenge. Prior studies have shown that preoperative transthoracic echocardiography (TTE) delays hip fracture surgery, but indications for TTEs are unclear. As such, the purpose of our study was to determine the proportion of TTEs for geriatric hip fracture patients that were indicated per established guidelines: American College of Cardiology/American Heart Association (ACC/AHA) guidelines, history of pulmonary hypertension, syncope/stroke work-up.

A retrospective case control study of 113 consecutive geriatric hip fracture patients who underwent preoperative TTEs from 1/2018 to 12/2019 at 2 Academic Level 1 Trauma Centers were examined. 113 matched (age±5 years, sex, fracture type, surgery, surgery within 1 year of TTE patient) hip fracture patients who did not undergo preoperative TTE were identified for comparison. The primary outcome was the proportion of TTEs that were indicated per established guidelines. Secondary outcome measures included: change in perioperative management, time to surgery, length of stay (LOS), 90-day complications and mortality, and 2-year mortality.

Eighty-one (71.7%) TTEs were indicated. Seventeen (15.0%) patients underwent additional preoperative interventions. More TTE patients had an arterial (p < 0.0001) and/or central line (p < 0.03). The TTE group had longer time to surgery with median time to surgery of 44.8 h vs. 24.2 h for the non-TTE group (p < 0.0001). LOS was longer for TTE patients with median LOS of 7 days vs. 5 days for the non-TTE patients (p < 0.0001). There was higher 90-day mortality for the TTE group (odds ratio 4.4, 95% confidence interval 1.3-14.7, p < 0.03) but no difference at 2-years.

Preoperative TTEs are associated with delay in surgery and higher 90-day mortality even though many of these TTEs are indicated per established guidelines and may result in changes in perioperative management. These results highlight the need for expedient preoperative evaluation of hip fracture patients.