In a patient with triple vessel disease (TVD) and reduced ejection fraction (EF) of 45%, should angioplasty or fracture of the neck of the femur be treated first?

Management of Femoral Neck Fracture in a Patient with Triple Vessel Disease and Reduced Ejection Fraction

In this 48-year-old male with a femoral neck fracture, triple vessel disease (TVD), and ejection fraction of 45%, coronary revascularization should be performed first, followed by fracture repair after appropriate delay for dual antiplatelet therapy.

Rationale for Coronary Revascularization Priority

The ACC/AHA guidelines provide Class I evidence (Level A) that coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 3-vessel disease, with survival benefit being greater when left ventricular ejection fraction is less than 0.50 1. This patient meets both criteria with TVD and EF of 45%, making preoperative revascularization a Class I indication 1.

Key Clinical Considerations

• Mortality risk: The patient's reduced EF (45%) combined with TVD places him at substantially elevated perioperative cardiac risk for orthopedic surgery 1
• Survival benefit: Surgical revascularization (CABG) or PCI in three-vessel disease with EF <50% demonstrates clear survival advantage over medical management alone 1, 2
• Fracture timing: While femoral neck fractures are urgent, they are not immediately life-threatening in a stable patient, allowing time for cardiac optimization 1

Recommended Revascularization Strategy

CABG is the preferred revascularization method for this patient with TVD and reduced EF, as it provides superior long-term outcomes compared to PCI in this anatomic and functional context 1, 3, 4.

If PCI is Selected Instead

If PCI is chosen due to surgical risk or patient/surgeon preference:

• Use bare-metal stents (BMS) followed by 4-6 weeks of dual antiplatelet therapy before proceeding to fracture surgery 1
• Avoid drug-eluting stents (DES) as they require 12 months of dual antiplatelet therapy, which would unacceptably delay fracture surgery and increase bleeding risk 1
• The ACC/AHA specifically recommends balloon angioplasty or BMS placement for patients requiring elective noncardiac surgery within 12 months 1

Timing Algorithm

If CABG is Performed:

1. Proceed with CABG for TVD revascularization 1, 3
2. Allow 7-14 days for surgical recovery and hemodynamic stabilization 1
3. Manage antiplatelet therapy: if clopidogrel was used, stop 5 days before orthopedic surgery 1, 3
4. Proceed with femoral neck fracture repair with aspirin continuation if possible 1

If PCI with BMS is Performed:

1. Complete PCI with BMS placement 1
2. Maintain dual antiplatelet therapy for 4-6 weeks 1
3. Stop clopidogrel 5 days before fracture surgery 1, 3
4. Continue aspirin perioperatively if bleeding risk permits 1

Management of the Femoral Neck Fracture During Waiting Period

While awaiting cardiac revascularization and the appropriate antiplatelet therapy window:

• Provide adequate analgesia to minimize sympathetic stress 1
• Maintain skeletal traction if fracture is unstable to prevent displacement 5, 6
• Initiate DVT prophylaxis immediately as femoral neck fractures carry 18.9-28% preoperative DVT risk 5, 6
• Optimize medical management including beta-blockers, statins, and ACE inhibitors 1, 7
• Monitor for DVT development with clinical surveillance, as bed rest >7 days increases VTE risk 5

Critical Pitfalls to Avoid

• Do NOT proceed directly to fracture surgery without addressing the TVD and reduced EF, as perioperative cardiac mortality would be unacceptably high 1
• Do NOT use drug-eluting stents if PCI is chosen, as the 12-month dual antiplatelet requirement would create an impossible clinical dilemma 1
• Do NOT delay fracture surgery beyond 6-8 weeks total if possible, as prolonged immobilization increases DVT risk (77.2% of preoperative DVTs in femoral neck fractures are isolated calf muscular venous thrombosis) 5, 6
• Do NOT perform therapeutic anticoagulation for isolated calf DVT before fracture surgery, as it increases bleeding without reducing thrombosis extension 5

Special Consideration for Unstable Cardiac Status

If the patient develops unstable angina, acute heart failure, or significant arrhythmias, these represent unstable cardiac conditions requiring immediate cardiac intervention regardless of fracture status 1, 4. In this scenario, coronary revascularization becomes emergent 1, 4.