Characteristics and Perioperative Outcomes of Fracture in Elderly patients with Chronic Heart Failure: A Cross-Sectional Study

Abstract

Purpose: The purpose is to observe the characteristics and perioperative outcomes of fracture in elderly adults with chronic heart failure (CHF).

Methods: We searched elderly patients (≥ 65 years) with CHF who developed fracture from January 2017 to February 2021. The gender, age, fracture types, electrocardiogram (ECG), laboratory results, comorbidities, complications, length of hospital stay and mortality of these patients were collected. Risk factors for perioperative cardiovascular disease (CVD) were identified.

Results: A total of 104 patients were brought into this study, including 65 female patients (62.5%) and 39 male patients (37.5%). The average age of these patients was 79.5 years old. In those 104 patients, 24 (23.1%) had HFrEF, 49 (47.1%) had HFmrEF, and 31 had HFpEF (29.8%). More than half of the patients had three or more comorbidities, and coronary artery disease was the most common comorbidity (60.6%). The incidence of perioperative CVD and non-cardiac complications was 59.6% and 95.1%, respectively. The mean length of hospital stay was 11.0 (7.0-19.0) days. The in-hospital mortality rate was 4.8%, and 1-year mortality rate was 19.2%. Arrhythmia (40%) was the most common perioperative CVD, and hypoalbuminemia (69.2%) was the most common non-cardiac complication. Multivariate analyses showed that age≥80 years, comorbidities≥3 and hip fracture were associated with increased rates of perioperative CVD.

Conclusion: Our results revealed elderly CHF patients with more comorbidities are prone to perioperative CVD after fracture, more comprehensive prevention and integrated management approaches will be required for these patients.

Introduction

With the acceleration of the aging of society, the number of elderly fracture patients is increasing, which has become an important public health concern[1, 2]. More fractures in the elderly are associated with osteoporosis, and hip fracture is the most common fractures in older adults with osteoporosis[3, 4]. One report showed that the 1-year mortality rate after fracture in elderly patients was 8.4–36%[5].

HF is another common cause of disability and mortality[6]. Moreover, HF and bone fracture share common risk factors. HF is considered a risk factor for fracture. Decreased skeletal muscle mass and bone density in older adults with CHF increase the risk of falls and fracture[7]. However, few studies on the association between fracture complications and HF. HF is classified according to left ventricular ejection fraction (LVEF). Previous studies found that HFpEF, HFmrEF and HFpEF can predict perioperative adverse events and mortality in older adults who underwent hip fracture surgery[8–10] .

The mechanism of perioperative complications and mortality is extremely complex. The studies have shown that cardiac complications are related to inflammatory response and perioperative traumatic stress[11, 12].

We retrospectively described the characteristics of different heart failure types and the effects on fracture complications and mortality. These findings help to understand characteristics of older fracture patients with CHF and make recommendations for the management of these patients.

Materials And Methods

Patients and Groups

We retrospectively collected data from January 2017 to February 2021 at a Level I trauma center in China. Elderly patients (age≥65) with chronic heart failure who developed bone fractures were included in our study. Patients with any of the following conditions were excluded from this study: (1) had pathological fracture, (2) had multiple fracture, (3) had secondary fracture, (4) incomplete medical information. CHF was defined as a clinical history of heart failure or reduced left ventricular (LV) ejection fraction (EF), patients were defined as HFrEF, HFmrEF or HFPEF according to current European guideline[13]. HFrEF patients had an LVEF ≤ 40%, HFmrEF patients had an LVEF of 40%–49%, and HFPEF patients had an LVEF ≥50%. This study protocol was approved by the Institutional Review Boards of Third Hospital of Hebei Medical University and the informed consent was waived for its retrospective nature.

Data Collection

We collected information included sex, age, and fracture types, comorbidities, echocardiographic and laboratory data，length of hospital stay and mortality. The echocardiographic data included LVEF, left ventricular end diastolic diameter (LVEDD), left ventricular fractional shortening (LEFS). Laboratory data  at time of hospital admission included white blood cell, haemoglobin(HB), haematocrit, platelet count, albumin(ALB), creatinine, sodium, potassium, C-reactive protein(CRP) and B-type natriuretic peptide (BNP). Perioperative CVD was defined as arrhythmia, angina pectoris, cardiac arrest, acute myocardial infarction. Other perioperative complications were hypoproteinemia, anemia, electrolyte disorders, deep vein thrombosis, pneumonia and acute cerebral infarction.

Statistical Analysis  

Continuous data are expressed as medians with 1st and 3rd quartiles. Nonparametric test was used to analyze differences between the groups. Categorical variables were expressed as numbers and percentages and Chi-squared or Fisher’s exact tests were used for comparing categorical variables. Univariate analysis and stepwise logistic regression were used to incorporate statistically significant variables into multivariate models to identify independent risk factors for perioperative CVD. All analyzes were performed using IBM SPSS software (IBM Corp, Armonk, NY). P<0.05 was considered as significance.

Results

As shown in Table 2, there were significant differences in LVEF, LVEDD, and LEFS among the three groups. The LVEF of patients in the HFrEF, HFmrEF, and HFpEF groups were 37.0 (34.2–37.7) 45.0 (42.2–46.0) 61.0 (57.0–64.0). HFrEF, HFmrEF had a larger LVEDD than HFPpEF, and LEFS was higher in HFpEF than in the other two groups (p<0.05). The white blood cell and haemoglobin and haematocrit in HFpEF were lower than those in the other two groups(p<0.05). There was no significant difference in other data among the three groups

In-hospital outcomes and 1-year mortality

Comparison of perioperative complications, length of hospital stay and mortality are presented in Table 3. The incidence of perioperative CVD and non-cardiac complications were 59.6% and 95.1%, respectively. Arrhythmia was the most common cardiac complication, with rates up to 40%. Other CVD were angina pectoris (24.0%), cardiac arrest (4.8%) and acute myocardial infarction (2.9%). In addition, non-cardiac complications included hypoproteinemia (69.2%), anemia (54.8%), electrolyte disorder (52.9%), deep vein thrombosis (33.7%), pneumonia (27.9%) and acute cerebral infarction (5.8%). The mean length of hospital stay was 11.0 (7.0–19.0) days. The in-hospital mortality rate was 4.8%, and the 1-year mortality rate was 19.8%. The number of complications, length of hospital stay, and mortality were not statistically different among the three groups.

The comparison of the perioperative CVD and without perioperative CVD

As can be seen in Table 4, univariate analysis showed that patients with perioperative CVD were older(≥ 80 years, p = 0.001), had more comorbidities (≥ 3, p = 0.037) and a higher proportion of hip fractures (93.5 vs 69.0,p = 0.002). They also had a higher hypernatremia rate (38.7 vs 19.0, p = 0.033) than patients without perioperative CVD. However, there were no statistically significant differences in gender, comorbidities and others among the three groups. (p > 0.05).

Risk Factors of perioperative CVD after Fractures

The results of the multivariate analysis are shown in Table 5. In the whole sample, age ≥ 80(OR 3.291, 95%CI 1.327–8.161), hip fractures(OR 6.116, 95%CI 1.602–23.334) and cormobidities ≥ 3(OR 2.887, 95%CI 1.137–7.330) were predictors of perioperative CVD in multivariate analysis.

Discussion

Fracture and CHF are serious diseases in the adults and result in higher disability, mortality and medical costs[14, 15]. Older patients are particularly prone to multiple complications in the perioperative period, and cardiac complications are often the most serious and can lead to death[16]. For these patients, early preventions should be administered. In this study, we found elderly CHF patients with more comorbidities are prone to perioperative CVD after fracture, the risk factors of perioperative CVD were identified, including age ≥ 80 years, comorbidities ≥ 3 and hip fracture.

We observed characteristics of elderly patients with CHF who developed fractures in our study, and find they were significantly older and had more comorbidities, and were significantly more female than male. More patients were female than male in our study, which is due to the reason that female have a longer life expectancy than male and are more prone to fractures after menopause [17, 18]. Hip fracture was the most common type of fractures in our study. Previous studies have shown that both systolic and diastolic heart failure increase the risk of hip fracture, and heart failure is an independent risk factor for 30-day mortality after hip fracture. Heart failure is divided into HFrEF, HFmrEF, HFpEF according to ejection fraction. Hip fracture incidence and age were higher in the HFpEF group, this result is consistent with other studies [19, 20]. Coronary artery disease was major comorbiditie in patients with CHF[21],this phenomenon was also observed in our study.

BNP is an endogenous cardiac hormone and most commonly used to assess the diagnosis and prognosis of patients with heart failure[22]. CRP is an inflammatory marker, and increased CRP associated with adverse outcomes in patients with CHF[23]. Our previous studies have shown that perioperative heart failure is associated with inflammatory responses and traumatic stress[11]. In our study, BNP and CRP were significantly higher than normal in fracture patients regardless of the type of heart failure. Therefore, we speculate that these patients may have suffered from inflammatory response and perioperative traumatic stress.

Previous studies have shown that complications are an important factor leading to high mortality in elderly patients who develop hip fracture[24, 25]. The results of our study revealed that perioperative risk for the CVD, other complications and death was comparable and similarly elevated in HFrEF, HFmrEF, and HFpEF patients. The incidence of CVD was as high as 59.6% in our study. Arrhythmia is the most common complication after non-cardiac surgery, and acute myocardial infarction is the most serious [26]. This is consistent with our findings. A study reported that the presence of HFPEF and HFmREF were predictors of perioperative CVD and mortality in elderly patients undergoing hip fracture surgery[10]. In patients with CHF, pain and anxiety activate the sympathetic nervous system. Increase vasoconstriction and cardiac stress by mediating the release of glucocorticoids and catecholamines, and ultimately lead to perioperative ischemia and myocardial injury.[11], the pre-existing cardiovascular risk may be exacerbated.

The most common complications after fracture were hypoalbuminemia, anemia and electrolyte imbalance in our study. Some research suggested that hypoalbuminemia, anemia, and electrolyte imbalance were also risk factors for perioperative cardiac adverse events in hip fracture patients[27]. Anemia caused by bleeding after fracture can lead to poor oxygen supply to the heart, resulting in increased cardiac contractility and increased oxygen consumption, thereby promoting adverse cardiac events[28]. Electrolyte disturbances can aggravate the susceptibility of the heart to ischemia[29] ,which increase the risk of cardiovascular adverse events. This suggests that we need to focus on the impact of non-cardiac complications on perioperative CVD.

We identify risk factor for perioperative CVD after fracture. Age ≥ 80 years, comorbidities ≥ 3 and hip fractures were associated with increased rates of perioperative CVD. Advanced age is an important risk factor for adverse perioperative events. It has been shown that advanced age was associated with increased risk of CVD[30]. Elder patients are more likely to combine with multiple basic diseases and have reduced tolerance to fracture trauma. The neuroendocrine metabolism and cardiac compensation in the elderly are weaker than those in the young. Therefore, they are prone to perioperative complications. In addition, a study found that the number of comorbidities in elderly hip fracture patients was associated with the occurrence of cardiovascular complications[31]. Interestingly, we found that hip fracture was an independent risk factor for perioperative CVD. Patients with hip fracture have a 2-fold increased cardiovascular risk compared with those without hip fracture[32]. In our study, patients with hip fracture have 6.1 times higher cardiovascular risk than patients with other fracture. For elderly patients with chronic heart failure after hip fracture, we should strengthen management to prevent the occurrence of perioperative CVD.

Conclusions

Elderly fracture patients with CHF have many and complex comorbidities, and they are prone to have perioperative CVD and multiple complications under traumatic stress. The management of these patients should be strengthened to reduce stress response and prevent the occurrence of perioperative CVD.

Abbreviations

chronic heart failure CHF; left ventricular ejection fraction LVEF; left ventricular end diastolic diameter LVEDD; left ventricular fractional shortening LEFS; haemoglobin HB; albumin ALB; C-reactive protein CRP; B-type natriuretic peptide BNP.

Declarations

Ethical approval and consent to participate

This study was approved by the Institutional Review Boards of Third Hospital of Hebei Medical University. The informed consent was waived for its retrospective nature and the Institutional Review Boards of Third Hospital of Hebei Medical University requested. All authors confirm that all methods were performed in accordance with the relevant guidelines and regulations

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to the data will also be used in further research. but are available from are available from Zhiqian Wang on reasonable request.

Conflicts of interest

The authors declare that there is no conflict of interest regarding the publication of 

this paper.

Funding 

None

Author contributions

ZQ.W and ZY.H conceived the study. YQ.Z collected the data and drafted the manuscript. MM.F, JF.G and YQ.Z supported study preparation and data collection. ZQ.W and ZY.H critically reviewed the manuscript for important intellectual content. All authors approved the final version of the manuscript.

Acknowledgements 

None.

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