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.
Limitations
Our study has some limitations worth discussing. First, this is a retrospective study and the inherent limitations of the design seem inevitable. Second, due to the small sample size, there is a possibility of selection bias. The conclusions drawn do not fully and reliably reflect the general clinical features. Third, patients without CHF were not included in our study.