What is the most appropriate recommendation for monitoring potential cardiac complications in the postoperative period for a patient with heart failure and severe obstructive sleep apnea (OSA) after surgical repair of a femoral neck fracture?

Postoperative Cardiac Monitoring After Femoral Neck Fracture Repair

No further cardiac testing is needed for this patient in the postoperative period (option B). The patient is clinically stable with no cardiac symptoms, has normal vital signs, and normal preoperative cardiac biomarkers and ECG.

Patient Risk Assessment

This 75-year-old man has several cardiac risk factors:

• Heart failure
• Severe obstructive sleep apnea (OSA) with CPAP non-adherence
• Stage 3 chronic kidney disease (GFR 45)

However, his current clinical status shows:

• No cardiac symptoms (no chest pain, palpitations, or shortness of breath)
• Stable vital signs (normal temperature, heart rate, blood pressure, respiratory rate)
• Normal oxygen saturation (93% on room air)
• Normal preoperative cardiac workup:
  • BNP 10 (not elevated)
  • Troponin <0.01 (normal)
  • Normal ECG with normal sinus rhythm and no ischemic changes

Evidence-Based Approach

Why Routine Postoperative ECG Is Not Indicated

The American Heart Association guidelines for electrocardiographic monitoring in hospital settings 1 recommend continuous cardiac monitoring for 48-72 hours only after open heart surgery, not after orthopedic procedures. For non-cardiac surgery patients, there is no recommendation for routine postoperative ECG in asymptomatic, hemodynamically stable patients.

Why Troponin Screening Is Not Indicated

While high-sensitivity troponin measurements can predict non-cardiac complications after major abdominal surgery 2, this patient:

1. Has already had a normal preoperative troponin
2. Is recovering well with adequate pain control
3. Shows no signs of hemodynamic instability
4. Had orthopedic (not vascular or major abdominal) surgery

The 2024 AHA/ACC guidelines for perioperative cardiovascular management 1 do not recommend routine postoperative troponin screening in asymptomatic patients after non-cardiac surgery, even in those with risk factors like OSA or heart failure.

Special Considerations for This Patient

Heart Failure

• The patient's heart failure appears well-compensated:
  • Normal BNP (10)
  • No respiratory distress
  • Normal vital signs
  • No evidence of fluid overload

Obstructive Sleep Apnea

• While OSA increases risk of postoperative cardiac complications 1, this patient shows:
  • Adequate oxygenation (93% on room air)
  • No respiratory distress
  • Normal heart rate

Kidney Disease

• Stage 3 CKD (GFR 45) is present but stable
• Creatinine 1.6 is consistent with his baseline kidney function
• No indication of acute kidney injury that might affect cardiac status

Management Recommendations

1. Continue standard postoperative monitoring of vital signs and oxygen saturation
2. Resume CPAP therapy as soon as possible to manage OSA 1
3. Monitor for clinical signs that would warrant cardiac evaluation:
   • New chest pain
   • Unexplained tachycardia
   • Hypoxemia
   • Hypotension
   • New shortness of breath

When Further Cardiac Testing Would Be Indicated

Additional cardiac testing would only be warranted if the patient develops:

• New cardiac symptoms
• Hemodynamic instability
• Unexplained tachycardia
• New arrhythmias
• Hypoxemia not explained by other causes

Conclusion

Based on the patient's stable clinical status, normal preoperative cardiac evaluation, and uncomplicated surgical recovery, no additional cardiac testing is indicated at this time. The most appropriate recommendation is option B: No further testing.