Postoperative Cardiac Management Following Hip Fracture Repair in Patient with Bioprosthetic Aortic Valve
Continue aspirin 81 mg daily as the sole antithrombotic agent for this patient's bioprosthetic aortic valve, maintain current blood pressure control with amlodipine 5 mg daily, and monitor for postoperative complications while optimizing rehabilitation.
Antithrombotic Management for Bioprosthetic Aortic Valve
Aspirin 75-100 mg daily is reasonable as sole antiplatelet therapy for all patients with bioprosthetic aortic or mitral valves 1. Your current regimen of aspirin 81 mg daily is appropriate and should be continued indefinitely 1.
- No additional anticoagulation is required for this patient's bioprosthetic valve in the absence of atrial fibrillation, venous thromboembolism, or severe LV dysfunction 2
- The 2014 AHA/ACC guidelines specifically recommend aspirin 75-100 mg daily for bioprosthetic valves as a Class IIa recommendation 1
- Vitamin K antagonist therapy is NOT indicated for bioprosthetic valves beyond the first 3 months post-implantation, and this patient is well beyond that timeframe 1
Common Pitfall to Avoid
Do not add warfarin or other anticoagulation solely based on the presence of a bioprosthetic valve—this increases bleeding risk without proven benefit in patients without other indications 2. The patient's recent hip surgery further increases bleeding risk, making aspirin monotherapy the safest approach.
Hypertension Management
Continue amlodipine 5 mg daily with current blood pressure of 139/68 mmHg representing adequate control 3.
- Blood pressure is at goal for elderly patients with coronary artery disease 3
- Amlodipine has demonstrated safety in patients with coronary disease and does not adversely affect heart failure outcomes 3
- Monitor for peripheral edema as a potential side effect, though none is currently present 3
- Elderly patients have 40-60% increased AUC with amlodipine, but the current 5 mg dose is appropriate 3
Coronary Artery Disease Management
Maintain aspirin 81 mg daily for secondary prevention of coronary events in this patient with prior CABG 1.
- Aspirin serves dual purpose: both for CAD secondary prevention and bioprosthetic valve thromboprophylaxis 1
- Monitor for any chest pain, dyspnea, or exertional symptoms that might indicate graft failure or progression of native disease 1
- The patient currently denies anginal symptoms, which is reassuring 1
Prosthetic Valve Surveillance
Obtain transthoracic echocardiography if any change in clinical symptoms or signs suggesting valve dysfunction occurs 1.
- Current examination shows no murmurs, which is reassuring for valve function 1
- Annual TTE is reasonable after the first 10 years of bioprosthetic valve implantation, even without clinical changes 1
- Monitor specifically for new murmurs, heart failure symptoms, or unexplained dyspnea that could indicate structural valve deterioration 1
Timing Consideration
The patient's bioprosthetic valve age is not specified in the note, but if approaching or beyond 10 years, schedule annual echocardiography regardless of symptoms 1.
Postoperative Anemia Management
Monitor CBC weekly and address the hemoglobin of 7.7 g/dL, which represents significant postoperative anemia.
- The anemia appears stable without active bleeding, but this level may impair rehabilitation efforts and increase cardiac stress
- Consider iron supplementation if iron studies demonstrate deficiency, particularly given low albumin (3.1) suggesting nutritional depletion
- Ensure adequate protein intake to support wound healing and address hypoalbuminemia
- Avoid NSAIDs (including ibuprofen PRN) in the setting of significant anemia and aspirin therapy due to additive bleeding risk—acetaminophen is safer for breakthrough pain
Critical Threshold
If hemoglobin drops below 7 g/dL or patient develops cardiac symptoms (chest pain, dyspnea, tachycardia), transfusion should be considered despite the patient's cardiovascular stability.
Perioperative Risk Stratification
This patient had elevated perioperative risk given combined AVR and CABG history 4.
- Patients with combined AVR + CABG have diminished late survival compared to age-matched controls (observed 36% vs predicted 45% at 10 years for bioprosthetic valves) 4
- Age, congestive heart failure, extent of coronary disease, peripheral vascular disease, and diabetes are significant predictors of late mortality 4
- Aggressive risk factor modification is essential: continue statin therapy (lipid panel pending), optimize blood pressure control, and maintain aspirin 1
Rehabilitation and Functional Recovery
Continue current physical and occupational therapy program with close monitoring of cardiac tolerance.
- The patient is appropriately engaged in PT/OT with walker assistance
- Monitor for exertional chest pain, dyspnea, or excessive fatigue during therapy sessions that might indicate cardiac decompensation 1
- Pain control is adequate with current oxycodone/acetaminophen regimen, which should facilitate participation in therapy
Follow-Up Schedule
Re-evaluate in 1 week or sooner with any acute cardiac changes 1.
- Monitor for chest pain, dyspnea, palpitations, syncope, or new edema 1
- Coordinate care among rehabilitation team, primary cardiologist, and primary care physician upon discharge 1
- Schedule outpatient cardiology follow-up within 3 months of discharge for comprehensive cardiovascular assessment 1
Laboratory Monitoring
- Weekly CBC to trend hemoglobin 1
- Renal function monitoring given amlodipine use and age 3
- Lipid panel at outpatient cardiology visit for hyperlipidemia management 1
Medication Reconciliation
Current cardiac medications are appropriate: