Acute coronary syndromes with significant troponin increase in patients with hip fracture prior to surgical repair: differential diagnosis and clinical implications

Myocardial infarction after hip fracture but before surgical repair is associated with a 30-day mortality as high as 30 % at 1 month. In Florence, since 2011, hip fractures are referred to a multidisciplinary hip fracture team including internal medicine specialists, anesthesiologists, and orthopaedic surgeons. The aim of the present investigation was to evaluate the clinical characteristics of patients with hip fracture who had at hospital admission a significant increase of troponin (>10 times reference levels), the diagnostic and therapeutic strategies adopted, and overall 1-year survival. Protocol at admission included careful clinical evaluation (including bedside echocardiography) in order to stratify surgical risk and schedule surgery and anaesthesiology strategy. 21/1025 patients had preoperative significant troponin increase. In sixteen patients, a diagnosis of NSTEMI was made, five presented with ST elevation. In five patients with NSTEMI considered at very high surgical risk (ASA >= 3, severe cognitive and functional impairment), surgery was not performed. None survived at 1 year. Hip surgery was performed in the other 11. Four underwent coronary revascularization after hip surgery. In this group, 1-year survival was 80 %. Four of five ST elevation patients fulfilled criteria for stress cardiomyopathy confirmed by angiography. Hip surgery was performed, and the patients are alive at 1-year follow-up. Close to 2 % of patients with hip fracture are found to have a significant troponin increase before surgery. Three out of four have an NSTEMI diagnosis. In patients undergoing hip surgery, survival at 1 year is close to 80 %. In patients with ST elevation at admission, stress cardiomyopathy should be considered in the differential diagnosis. This clinical condition is associated with a favourable prognosis after hip surgery.