What are the guidelines for cardiac clearance in a patient with a femur fracture?

Cardiac Clearance Guidelines for Patients with Femur Fracture

For patients with femur fractures, cardiac clearance should not delay surgery beyond 48 hours, and echocardiography should only be performed for specific clinical indications without causing undue surgical delay. 1

Basic Cardiac Assessment Requirements

• An electrocardiogram (ECG) is required for all elderly patients with hip fracture 1
• Routine chest radiographs are not necessary but may be useful in patients with newly diagnosed heart failure or pneumonia 1
• Basic laboratory tests should include electrolytes to identify hypokalaemia (associated with new-onset atrial fibrillation) and hyperkalaemia (which may indicate rhabdomyolysis in immobilized patients) 1

Indications for Echocardiography

Echocardiography may be indicated in specific circumstances:

• To establish left ventricular function if the patient is breathless at rest or on low-level exertion 1
• To investigate an ejection systolic murmur in the aortic area, particularly if significant aortic stenosis is suggested by two or more of: 1
  • History of angina on exertion
  • Unexplained syncope or near syncope
  • Slow rising pulse
  • Absent second heart sound
  • Left ventricular hypertrophy on ECG without hypertension

Important Principles for Cardiac Clearance

• "Awaiting echocardiography" is an unacceptable reason to delay surgery 1
• If echocardiography cannot be obtained without causing delay, proceed to surgery with appropriate modifications 1
• When aortic stenosis is suspected but echocardiography would delay surgery, most clinicians favor proceeding with general anesthesia and invasive blood pressure monitoring 1
• Patients should undergo echocardiography in the early postoperative period if indicated but not performed preoperatively 1

Management of Specific Cardiac Conditions

Atrial Fibrillation

• All patients in AF should have a ventricular rate <100/min 1
• Treat factors that may lead to new or fast AF: hypokalaemia, hypomagnesaemia, hypovolaemia, sepsis, pain, and hypoxaemia 1
• If these treatments are ineffective, acute ventricular rate control may be achieved using beta-blockers (metoprolol) or verapamil 1

Anticoagulation Management

• For patients on warfarin: INR should be <2 for surgery and <1.5 for neuraxial anesthesia 1
• Small amounts of vitamin K may be used to reverse warfarin effects 1
• Supplemental perioperative anticoagulation with heparins is usually indicated 1
• Warfarin should be recommenced 24 hours after surgery 1
• For patients on clopidogrel: do not delay surgery or administer platelets prophylactically, but expect marginally greater blood loss 1

Implantable Cardiac Devices

• Early preoperative consultation with a cardiologist is required for patients with pacemakers or implantable cardioverter defibrillators 1
• This consultation should establish the device type and develop a plan for intraoperative management 1

Timing Considerations

• Surgery should ideally be performed within 48 hours of hospital admission 1
• Delaying surgery beyond 48 hours is associated with prolonged inpatient stay, increased morbidity (pressure sores, pneumonia, thromboembolic complications), and increased mortality 1, 2
• There is no evidence that delaying surgery to allow preoperative physiological stabilization improves outcomes 1

Different Guideline Approaches

Guidelines differ in their recommendations for cardiac clearance:

• BOA/BSG (2007): Echocardiogram may be useful if obtained without delay, but absence should not delay fracture repair 1
• SIGN (2009): Routine additional cardiac investigation not required; echocardiography only for suspected aortic stenosis 1
• AAGBI (2011): Echocardiography indicated for specific conditions but should not delay surgery 1
• NCEPOD (2001): Asymptomatic cardiac murmur may indicate significant cardiac disease and should be investigated preoperatively 1

Common Pitfalls to Avoid

• Delaying surgery for unnecessary cardiac testing in low-risk patients 3
• Failing to identify high-risk cardiac conditions that could significantly impact anesthetic management 4
• Using "awaiting echocardiography" as a reason to delay surgery beyond 48 hours 1
• Overlooking the importance of early surgery (within 24-48 hours) in reducing complications related to immobilization 2
• Not considering the balance between cardiac risk assessment and the risks of surgical delay 3

Practical Algorithm for Cardiac Clearance

1. Perform basic cardiac assessment (ECG, electrolytes) for all patients 1
2. Identify specific indications for echocardiography (breathlessness, significant murmur) 1
3. If echocardiography is indicated but would delay surgery:
   • Proceed to surgery with appropriate modifications (general anesthesia, invasive monitoring) 1
   • Schedule echocardiography for early postoperative period 1
4. Manage specific cardiac conditions (AF, anticoagulation) without unnecessary delay 1
5. Aim for surgery within 48 hours of admission 1