Clinical Scorecard: Management and Prevention of Cardiovascular Complications in Elderly and Frail Patients Undergoing Elective or Post-Traumatic Hip Surgery: A Consensus Statement from Multiple ESC Councils and Associations

At a Glance

Key Highlights

• Frailty and cardiovascular diseases synergistically increase vulnerability to falls and complications after hip surgery.
• Syncope, orthostatic hypotension, and polypharmacy are major contributors to falls and fractures in older adults.
• Multidisciplinary approach focusing on cardiovascular assessment, frailty management, anesthesia considerations, thrombotic prevention, infection and delirium prevention, and integrated rehabilitation is essential.

Guideline-Based Recommendations

Diagnosis

• Assess for syncope and orthostatic hypotension in older adults, considering unexplained falls as possible syncope.
• Evaluate cardiovascular diseases and frailty status pre-operatively.
• Exercise caution with diagnostic tests for orthostatic hypotension in bed-confined hip fracture patients.

Management

• Optimize management of concomitant cardiovascular diseases and frailty before surgery.
• Educate patients to avoid syncope triggers, maintain hydration, and perform physical counter-pressure maneuvers.
• Adjust or discontinue causative drugs increasing syncope and fall risk, including antihypertensives and psychotropics.
• Implement peri- and post-operative care focusing on anesthesia safety, thrombosis prevention, infection and delirium prevention, and tailored rehabilitation.

Monitoring & Follow-up

• Monitor cardiovascular status closely throughout pre-, peri-, and post-operative phases.
• Observe for signs of syncope, orthostatic hypotension, and adverse drug reactions.
• Assess rehabilitation progress with attention to cardiovascular health and fall risk.

Risks

• Increased risk of falls and fractures due to syncope, orthostatic hypotension, and polypharmacy.
• Worsening frailty and disability post-hip surgery from cardiovascular complications.
• Potential adverse drug reactions contributing to cardiovascular instability and falls.

Patient & Prescribing Data

Older adults and frail patients undergoing hip surgery

Careful review and adjustment of cardiovascular and psychotropic medications to minimize syncope and fall risk; emphasis on hydration and education to prevent orthostatic hypotension.

Clinical Best Practices

• Adopt a multidisciplinary approach integrating cardiology, orthopaedics, geriatrics, anesthesia, nursing, and rehabilitation.
• Perform comprehensive cardiovascular and frailty assessments pre-operatively.
• Educate patients and caregivers on syncope prevention and hydration strategies.
• Optimize medication regimens to reduce polypharmacy and adverse effects.
• Implement peri-operative protocols to prevent thrombotic events, infections, and delirium.
• Establish integrated rehabilitation programs focusing on cardiovascular health and fall prevention.

References

• ESC Guidelines on Syncope 2018
• WHO Decade of Healthy Ageing 2020–2030