The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery

Abstract Purpose The post-operative mortality after hip fracture surgery is high and has remained largely unchanged during the last decades. The Revised Cardiac Risk Index (RCRI) is a tool used to evaluate the 30-day risk of, among other outcomes, post-operative mortality. The aim of this study is to determine the association between the RCRI score and post-operative mortality in patients undergoing hip fracture surgery. Methods Data was obtained from the national hip fracture register which was cross-referenced with patients’ electronic hospital records. All adults who underwent primary emergency hip fracture surgery in Orebro County, Sweden, between January 1, 2013 and December 31, 2017, were included. Patients were divided into two cohorts: low RCRI (score = 0–1) and high RCRI (score ≥ 2). A Poisson regression model was employed to investigate the association between a high RCRI score and 30- and 90-day post-operative mortality. Results A total of 2443 patients, of whom 446 (18%) had a high RCRI score, were included in the current study. When adjusting for age, sex, comorbidities and type of surgery, the incidence of 30-day mortality increased by 46% in the high RCRI cohort (adj. IRR 1.46, 95% CI, 1.10–1.94, p = 0.010). Similar results were observed for 90-day mortality (adj. IRR 1.50, 95% CI, 1.21–1.84, p < 0.001). Conclusion The RCRI is applicable to patients that undergo surgery for traumatic hip fractures. A high RCRI score is associated with an increased incidence of both 30- and 90-day post-operative mortality. Future studies to evaluate these findings are needed.

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Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000778 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000778

Author(s):

Maximilian Peter Forssten ◽

Ahmad Mohammad Ismail ◽

Tomas Borg ◽

Rebecka Ahl ◽

Per Wretenberg ◽

...

Keyword(s):

Hip Fracture ◽

Risk Index ◽

Postoperative Mortality ◽

Cardiac Risk ◽

Significant Linear Trend ◽

Hip Fracture Surgery ◽

Cardiac Risk Index ◽

Postoperative Myocardial Infarction ◽

National Quality ◽

Fracture Surgery

ObjectivesThe Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.MethodsAll adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.Results134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.ConclusionAn increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.Levels of evidenceLevel III.

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Predictive Values of Preoperative Characteristics for 30-Day Mortality in Traumatic Hip Fracture Patients

Journal of Personalized Medicine ◽

10.3390/jpm11050353 ◽

2021 ◽

Vol 11 (5) ◽

pp. 353

Author(s):

Yang Cao ◽

Maximilian Peter Forssten ◽

Ahmad Mohammad Ismail ◽

Tomas Borg ◽

Ioannis Ioannidis ◽

...

Keyword(s):

Hip Fracture ◽

Risk Index ◽

Postoperative Mortality ◽

Predictive Ability ◽

Cardiac Risk ◽

Predictive Values ◽

Hip Fracture Surgery ◽

Asa Classification ◽

Risk Of Mortality ◽

Fracture Surgery

Hip fracture patients have a high risk of mortality after surgery, with 30-day postoperative rates as high as 10%. This study aimed to explore the predictive ability of preoperative characteristics in traumatic hip fracture patients as they relate to 30-day postoperative mortality using readily available variables in clinical practice. All adult patients who underwent primary emergency hip fracture surgery in Sweden between 2008 and 2017 were included in the analysis. Associations between the possible predictors and 30-day mortality was performed using a multivariate logistic regression (LR) model; the bidirectional stepwise method was used for variable selection. An LR model and convolutional neural network (CNN) were then fitted for prediction. The relative importance of individual predictors was evaluated using the permutation importance and Gini importance. A total of 134,915 traumatic hip fracture patients were included in the study. The CNN and LR models displayed an acceptable predictive ability for predicting 30-day postoperative mortality using a test dataset, displaying an area under the ROC curve (AUC) of as high as 0.76. The variables with the highest importance in prediction were age, sex, hypertension, dementia, American Society of Anesthesiologists (ASA) classification, and the Revised Cardiac Risk Index (RCRI). Both the CNN and LR models achieved an acceptable performance in identifying patients at risk of mortality 30 days after hip fracture surgery. The most important variables for prediction, based on the variables used in the current study are age, hypertension, dementia, sex, ASA classification, and RCRI.

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Vitamin D Levels and Nutritional Risk Index: Mobility and Mortality After Hip Fracture Surgery (P01-013-19)

Current Developments in Nutrition ◽

10.1093/cdn/nzz028.p01-013-19 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

Author(s):

Lihong Hao ◽

Yvette Schlussel ◽

Jeffrey Carson ◽

Sue Shapses

Keyword(s):

Vitamin D ◽

Hip Fracture ◽

Vitamin D Deficiency ◽

Risk Index ◽

Nutritional Risk ◽

Walking Ability ◽

Hip Fracture Surgery ◽

Vitamin D Levels ◽

Nutritional Risk Index ◽

Fracture Surgery

Abstract Objectives Hip fractures are associated with a high rate of morbidity and mortality, and successful ambulation after surgery is an important outcome in this patient population. This study aims to determine whether 25-hydroxyvitamin D (25(OH)D) or the Geriatric Nutritional Risk Index (GNRI) is associated with short term mortality or ability to walk after hip fracture surgery. Methods Patients undergoing hip fracture repair were included in this study. Mortality and walking ability were assessed at 30 and 60 days after hip fracture surgery. Pre-operative serum albumin and 25(OH)D were measured. Patients were characterized with 25(OH)D <12 ng/mL, 12 to <20, 20 to <30 or ≥30. GNRI was calculated from albumin and body weight and patients were categorized into major/moderate nutritional risk (<92), low risk (92 to <98) or in good nutritional status (≥98). Results Of the 290 patients (82 ± 7 years, BMI 25 ± 5 kg/m2), 73% were females. Compared to patients with vitamin D deficiency (<12 ng/mL), those with vitamin D levels in higher categories had increased ability to walk at 30 days (P = 0.031): 12 to <20 ng/ml (adjusted odds ratio = 2.61; 95% confidence interval = 1.13–5.99); 20 to <30 ng/ml (3.48; 1.53–7.95); ≥30 ng/ml (2.84; 1.12–7.20). In addition, patients also had increased mobility at 60 days in these same higher vitamin D categories 12 to <20 (2.67; 1.14–6.25); 20 to <30 (3.42; 1.46–8.00); ≥30 ng/ml (3.67; 1.37–9.82) compared to the reference group (<12 ng/mL; P = 0.028). There was no association of vitamin D with mortality at either time point. GNRI was not associated with mortality or walking ability. Conclusions In patients with hip fracture, vitamin D deficiency (<12 ng/mL) was associated with reduced ambulation after surgery, whereas GNRI was not associated with any outcomes. Mechanisms that attenuate mobility due to vitamin D deficiency should be examined in future studies. Funding Sources ONE Nutrition Grant to SAS and JLC.

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Can ASA grade or Goldman's cardiac risk index predict peri‐operative mortality? A study of 16 227 patients

Anaesthesia ◽

10.1111/j.1365-2044.1997.074-az0074.x ◽

1997 ◽

Vol 52 (3) ◽

pp. 203-206 ◽

Cited By ~ 113

Author(s):

G. Prause ◽

B. Ratzenhofer‐Comenda ◽

G. Pierer ◽

F. Smolle‐Ju¨ttner ◽

H. Glanzer ◽

...

Keyword(s):

Operative Mortality ◽

Risk Index ◽

Cardiac Risk ◽

Cardiac Risk Index

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Association between Intravenous Iron Therapy and Short-term Mortality Risk in Older Patients Undergoing Hip Fracture Surgery: An Observational Study

10.21203/rs.3.rs-320715/v1 ◽

2021 ◽

Author(s):

Silas Zacharias Clemmensen ◽

Kristian Hay Kragholm ◽

Dorte Melgaard ◽

Lene Torp Hansen ◽

Johannes Riis Jensen ◽

...

Keyword(s):

Hip Fracture ◽

Intravenous Iron ◽

Iron Therapy ◽

Short Term ◽

Treatment Groups ◽

Hip Fracture Surgery ◽

Post Surgery ◽

Short Term Mortality ◽

Intravenous Iron Therapy ◽

Fracture Surgery

Abstract Background: Anemia is common among ortho-geriatric hip fracture patients and is associated with prolonged recovery and increased postoperative mortality rate. Intravenous iron seems to increase hemoglobin recovery and reduce the mortality rate in patients undergoing orthopedic surgeries. This study investigated the association between short-term mortality risk and intravenous iron therapy in older patients undergoing hip fracture surgery.Methods: This observational study included 210 patients undergoing hip fracture surgery from July 2018 to Maj 2020. These 210 patients were alive and had a hemoglobin ≤ 6.5mmol/L on the 3rd postoperative day. In May 2019 a local intravenous iron therapy protocol was implemented and recommended intravenous iron (Monofer ©) if hemoglobin on the 3rd postoperative day was ≤ 6.5 mmol/L. According to treatment of postoperative anemia between 1st and 3rd day post-surgery, the patients were divided into four groups: No treatment (n=52), blood transfusion (n=38), IV Monofer (n=80) and blood transfusion & IV Monofer (n=40). Primary outcome was 30-day mortality post-surgery. The secondary outcome was the impact on hemoglobin level 14-30 days postoperatively. Multivariable Cox regression was used to estimate the 30-day mortality standardized for covariates. Results: Of 210 patients, 17 (8.1%) died within 30-days after surgery. There was a significantly lower mortality among the patients who received IV Monofer compared to those who received no treatment (HR: 0.17, 95% CI: [0.03-0.93], P = 0.041). Among the 86 patients with available hemoglobin measurements within 14 to 30 days post-surgery, there was no significant difference in hemoglobin level between the various treatment groups (mean 6.6 mmol/L, P = 0.1165).Conclusion: IV Monofer on the 3rd postoperative day in older hip fracture patients seemed to reduce 30-day mortality compared with no treatment. No significant differences in hemoglobin levels between 14-30 days post-surgery across treatment groups were found, although this was assessed in a subset of patients with available hemoglobin levels warranting further study. Trial registration: NA

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P6252Diagnostic and prognostic accuracy of preoperative NT-proBNP added to revised cardiac risk index in elderly patients with hip fracture

European Heart Journal ◽

10.1093/eurheartj/ehz746.0852 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

I Iglesias Garriz ◽

M D Ruiz-Villa ◽

J Idoate ◽

S Jimenez Mola ◽

A Sanchez-Robles ◽

...

Keyword(s):

Hip Fracture ◽

Risk Index ◽

Positive Likelihood Ratio ◽

Cardiac Risk ◽

Clinical Value ◽

Predictive Values ◽

Prognostic Accuracy ◽

Net Reclassification Improvement ◽

Cardiac Risk Index ◽

C Statistic

Abstract Background The identification of patients at highest risk after surgery for hip fracture could be of clinical value to implement post-operative actions to lessen mortality. We sought to investigate the utility of Revised Cardiac Risk Index (RCRI) and NT-proBNP in this scenario. Methods Patients older than 75 years with hip fracture treated with surgery were prospectively included. The end-point was overall mortality at 30 days. Results We enrolled 410 patients surgically-treated for hip fracture, 31 (7.6%) died during the 30-day follow-up. Patients who died were 3.5 years older (95% CI 1.3 to 5.6); p=0.001, and had a lower prevalence of diabetes mellitus.The prevalence of heart failure was more prevalent among patients who died: difference of proportions 35.7% (95% CI 16.0 to 55.3); p<0.001 and more patients were not in sinus rhythm with a difference of 25.4% (95% CI 5.6 to 45.1); p<0.001. Adding NT-proBNP to a logistic regression model with RCRI as an independent variable, improved the diagnostic and prognostic metrics, with significant changes in specificity (0.59 vs 0.70, p<0.001) and predictive values: positive likelihood ratio (LR) 1.89 vs 2.49, p<0.001, negative LR 0.38 vs 0.33, p<0.001. The C-statistic (0.69 vs 0.77, p=0.002) and the net reclassification improvement were also improved. Conclusion Adding preoperative NT-proBNP to RCRI to appraise the risk of overall 30-day mortality rate after hip surgery improves the prediction accuracy of RCRI alone.

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Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register

BMJ Open ◽

10.1136/bmjopen-2019-035598 ◽

2020 ◽

Vol 10 (5) ◽

pp. e035598

Author(s):

Tom Lian ◽

Eva Dybvik ◽

Jan-Erik Gjertsen ◽

Håvard Dale ◽

Marianne Westberg ◽

...

Keyword(s):

Hip Fracture ◽

Antibiotic Prophylaxis ◽

Prophylactic Antibiotics ◽

University Hospitals ◽

National Guidelines ◽

Hip Fracture Surgery ◽

Fracture Register ◽

New Guidelines ◽

Health Need ◽

Fracture Surgery

ObjectiveWe assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013.DesignThe data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines.SettingAll hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016.ParticipantsWe studied 13 329 hemiarthroplasties (HAs) for acute hip fracture.Main outcome measureType and timing between first and last dose of prophylactic antibiotics compared with the national guidelines.ResultsBefore the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals’ adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals.ConclusionsThe change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

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Preoperative cardiac risk factors associated with in-hospital mortality in elderly patients without heart failure undergoing hip fracture surgery: a single-centre study

Postgraduate Medical Journal ◽

10.1136/postgradmedj-2020-138679 ◽

2020 ◽

pp. postgradmedj-2020-138679

Author(s):

Vedat Çiçek ◽

Tufan Cinar ◽

Mert Ilker Hayiroglu ◽

Şahhan Kılıç ◽

Nürgül Keser ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Hip Fracture ◽

Elderly Patients ◽

Hospital Mortality ◽

Cardiac Risk ◽

Cardiac Risk Factors ◽

Hip Fracture Surgery ◽

Single Centre Study ◽

Fracture Surgery

IntroductionIn the present study, our aim was to ascertain the preoperative cardiac risk factors related to the in-hospital mortality in the elderly patients (aged over 65 years) who required preoperative cardiology consultation for hip fracture surgery.Material and MethodsThe present study was a retrospective, single-centre study, which enrolled consecutive elderly patients without heart failure scheduled for hip fracture surgery in our institution. In all patients, an anesthesiologist performed a detailed preoperative evaluation and decided the need for the cardiac consultation. Patients underwent preoperative cardiac evaluation by a trained cardiologist using the algorithms proposed in the recent preoperative guidelines. The in-hospital mortality was the main outcome of the study.ResultsIn total, 277 elderly patients undergoing hip fracture surgery were enrolled in this analysis. The overall in-hospital mortality rate was 12.1% (n=30 cases). In a multivariate analysis, we found that insulin dependency, cancer, urea, presence of atrial fibrillation (AF) (OR: 3.906; 95% CI 1.470 to 10.381; p=0.006) and pulmonary artery systolic pressure (PASP) (OR: 1.057; 95% CI 1.016 to 1.100; p=0.006) were the predictors of in-hospital mortality. The receiver operating characteristic curve analysis revealed that the optimal value of PASP in predicting the in-hospital mortality was 35 mm Hg (area under the curve=0.71; 95% CI 0.60 to 0.81, p<0.001) with sensitivity of 87.7% and specificity of 59.5%.ConclusionThe present research found that the preoperative cardiac risk factors, namely AF and PASP, might be associated with increased in-hospital mortality in elderly patients without heart failure undergoing hip fracture surgery.

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