What to do in a patient with a hip hematoma, status post hip replacement 3 months ago, with mild elevation of troponin (trip) and negative electrocardiogram (EKG), past medical history of coronary artery bypass grafting (CABG) x 4 and percutaneous coronary intervention (PCI)?

From the Guidelines

For a patient with a hip hematoma three months after hip replacement who has mildly elevated troponin levels with a negative EKG and history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), I strongly recommend a conservative approach with close monitoring of cardiac status and hematoma management. This approach is based on the latest guidelines and evidence, including the 2019 recommendations for institutions transitioning to high-sensitivity troponin testing 1, which suggest that mildly elevated troponin levels after PCI may not necessarily indicate a type 4A MI.

Key Considerations

• Obtain orthopedic consultation to evaluate the hematoma through imaging (ultrasound or CT) to determine its size and if it requires drainage.
• Monitor cardiac status with serial troponin measurements every 6-8 hours for 24 hours and repeat EKG if symptoms change, as recommended by the 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.
• Continue the patient's cardiac medications, particularly antiplatelet therapy, unless active bleeding is present, as suggested by the guidelines for UA/NSTEMI patients in whom a conservative strategy is selected 1.
• If the hematoma is expanding or causing significant pain, consider aspiration under ultrasound guidance.
• For pain management, use acetaminophen rather than NSAIDs to avoid further bleeding risk.
• The patient should be monitored for signs of infection including fever, increasing pain, or erythema around the surgical site. This approach balances managing the hematoma while addressing the cardiac concerns, recognizing that post-operative hematomas are common after hip replacement but require careful monitoring in patients with significant cardiac history.

From the Research

Patient Management

• The patient has a hip hematoma, status post hip replacement 3 months ago, with mild elevation of troponin (trip) and negative electrocardiogram (EKG), and a past medical history of coronary artery bypass grafting (CABG) x 4 and percutaneous coronary intervention (PCI) 2, 3.
• The management of this patient should take into account the potential risk of infection, as the occurrence of a hematoma after hip or knee replacement that requires surgical revision is associated with an increased risk of infection 4.
• The patient's history of CABG and PCI suggests that they have coronary artery disease, and the mild elevation of troponin may indicate perioperative myocardial infarction 3.

Anticoagulant and Antiplatelet Therapy

• Anticoagulant therapy is an important aspect of managing patients with coronary artery disease, but it must be monitored and evaluated due to the risk of bleeding 5.
• The use of antiplatelet therapy in patients with acute coronary syndrome and thrombocytopenia is not well established, and treatment should be individualized based on specific clinical circumstances 6.
• The patient's history of CABG and PCI may require adjustment of their antiplatelet and anticoagulant therapy, and the potential risk of bleeding should be carefully considered 2, 5.

Infection Risk and Management

• The patient's hip hematoma should be evaluated for potential infection, and microbiology samples should be collected if the hematoma is drained surgically more than 72 hours after the joint replacement procedure 4.
• The patient's diabetes status and other comorbidities should be taken into account when evaluating the risk of infection, as diabetes was more prevalent in patients with infected hematomas 4.
• Early revision and empirical postoperative antibiotic therapy may be necessary to prevent the occurrence of late infections 4.