Clinical outcomes
Our ultimate goal was to investigate the prognosis of elderly hip fracture patients with both paroxysmal and permanent AF, as well as the prognosticators of elderly hip fracture patients with perioperative paroxysmal AF, with a prevalence of 7.5% in our group. Permanent AF had significantly more heart failure, all-cause mortality, and hypokalemia and hyponatremia complications than paroxysmal AF. In our cohort, elderly hip fracture patients with permanent atrial fibrillation had generally poorer outcomes than those with paroxysmal AF. Moreover, permanent AF was identified as a separate risk factor for all-cause mortality post-surgery, in addition to other baseline conditions and multiple comorbidities. Age, pulmonary infection, and hyponatremia were also independent risk factors for death in these patients. The incidence of hip fracture in elderly patients with paroxysmal AF was linked to ACCI, hypertension, and COPD.
Comparison with other studies
AF, even in those without other TCVRFs (standard cerebrocardiovascular risk factors), is an independent hazard for stroke and all-cause cardiovascular mortality [4]. AF and heart failure are two conditions that are often associated with each other, as AF facilitates HF to occur and vice-versa[19]. The cause of AF and heart failure may be a 25% decrease in cardiac ejection fraction, which in turn leads to a decrease in cardiac coronary perfusion. This, in turn, causes a decrease in coronary perfusion, and a decrease in the blood supply to the atria, thus resulting in an atrial heart rhythm disorder[20–22]. Patients with atrial fibrillation demonstrate a significantly greater incidence of stress ulcer than those without. It is thought to occur with an incidence of 0.2–2% in the post-operative period, according to several reviews, although this is lower than many of the post-operative complications[23]. Our research reveals that those with atrial fibrillation have a significantly higher prevalence of hypokalemia than those without. In elderly adults with AF, this rate is 30.98% of the total. Hypokalemia has a strong association with death from cardiovascular causes[24]. The incidence of acute cerebrovascular disease in patients with AF is significantly greater than in those without AF, and ischemic stroke or transient ischemic attack (TIA) is the first manifestation of AF in 2 to 5% of them, with a fivefold increased risk of stroke.[25].
We find that in patients with AF, permanent AF is an independent indicator of mortality. The prevailing view is that permanent and persistent AF patterns are associated with poorer survival[26, 27]. Amalia Baroutid's study revealed that, at a median follow-up of 31 months (interquartile range 10 to 52 months), 37.3% of patients perished. In comparison to those with paroxysmal AF, permanent AF patients had a higher mortality rate (adjusted hazard ratio (aHR),1.37; 95% confidence interval [CI],1.08–1.74, P ¼).009), but similar rates of CV mortality or hospitalization (aHR, 1.09; 95%CI, 0.91–1.31, P ¼ .35)[28–30]. This result is in line with our findings.
Pulmonary infection is an independent indicator of AF mortality in those with hip fracture and AF. Pneumonia is a common complication of hip fracture and can increase mortality by up to four times[31]. Patients with pneumonia may cough, produce sputum, have difficulty breathing or have fever[32]. Though progress has been made in the production of antibiotics, mortality from pneumonia persists, particularly as the amount of high-risk patients has risen [33].
A serum sodium concentration of less than 135 mEq/L is what defines hyponatremia, an electrolyte abnormality that is often seen in heart failure patients and has been linked to adverse results. Its prevalence ranges from 13.8–33.7%. Hyponatremia is an independent predictive risk factor for death in hip fracture patients with comorbid AF, as confirmed by the study of Aydın Akyüz et al[34–36].
Charlson et al. created the Charlson Comorbidity Index, a tool for assessing the mortality risk due to comorbidities[37]. However, there is no research on the correlation between ACCI (age-adjusted Charlson Comorbidity Index) and perioperative AF in hip fracture patients. In our study, ACCI is identified as a significant predictor of perioperative AF in geriatric hip fracture patients. Hypertension and COPD have been identified as risk factors for perioperative AF associated with surgery [13]. The results of Monika Gawałko et al are consistent with ours. Hypertension is prevalent in > 70% of patients with AF. Patients suffering from hypertension have a significantly greater chance of AF, potentially up to 73% higher in risk. Current guidelines recommend that systematic AF screening may be warranted in all patients aged ≥ 65 years with at least one cardiovascular disease, including hypertension.[38]
Both AF and COPD are significant global contributors to health-care burden, and they frequently coexist due to their shared pathophysiology. A study utilizing the Spanish National Hospital Discharge Database discovered that COPD is a common comorbidity in patients hospitalized for AF[39]. In the Atherosclerosis Risk in Community (ARIC) cohort study [40], COPD and reduced lung function have been independently linked to the emergence of AF, despite the presence of risk factors for cardiovascular disease (e.g. smoking) in many COPD patients that may be confounding factors.[40]. The co-existence of COPD and AF is a well established fact: Sidney et al. A cohort study of 45,966 patients was conducted retrospectively, with a case-control approach. They found a 4.41-fold increased risk of AF in COPD, something that was reproduced[41]. COPD triggers pathological processes including hypoxia, electrolyte imbalances and altered pulmonary hemodynamics. Oxidative stress and chronic systemic inflammation, resulting in hypoxia, increased expression of matrix metalloproteinases (MMPs) and atrial remodelling, can be the catalysts for the emergence of arrhythmia. In particular, COPD-induced atrial myocyte dysfunction and fibrosis are the cause of this (2010)[42]. Pulmonary hypertension and elevated pCO2 levels also result from hypoxia, are risk factors for AF, as is elevated systolic blood pressure[43]. Finally, COPD patients may have low serum potassium levels due to electrolyte disturbances caused by overuse of corticosteroids or beta-blockers. The p-wave's length is augmented, a hazard factor for AF, as a result of this.[44].