Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study

L. Sinvani, Zucker School of Medicine at Hofstra/Northwell
D. A. Mendelson
A. Sharma, Zucker School of Medicine at Hofstra/Northwell
C. N. Nouryan, Zucker School of Medicine at Hofstra/Northwell
J. S. Fishbein, Northwell Health
M. G. Qiu
R. Zeltser, Zucker School of Medicine at Hofstra/Northwell
A. N. Makaryus, Zucker School of Medicine at Hofstra/Northwell
G. P. Wolf-Klein, Zucker School of Medicine at Hofstra/Northwell

Abstract

© 2020 The American Geriatrics Society BACKGROUND/OBJECTIVES: For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN: Retrospective chart review. SETTING: Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS: Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS: Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS: Although 34.3% (n = 370) had a preoperative TTE,.7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] =.8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P <.001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P <.001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P <.001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION: This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population.