2025 C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Postoperative Myocardial Infarction and Cardiac Arrest Following Primary Total Knee and Hip Arthroplasty: Rates, Risk Factors, and Time of Occurrence Philip J. Belmont Jr., MD, Gens P. Goodman, DO, Nicholas A. Kusnezov, MD, Charles Magee, MD, MPH, Julia O. Bader, PhD, Brian R. Waterman, MD, and Andrew J. Schoenfeld, MD, MSc Investigation performed at William Beaumont Army Medical Center, El Paso, Texas
Background: Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty. Methods: The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed. Results: For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined). continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Disclaimers: Some authors are employees of the U.S. Federal Government (A.J.S.) and the United States Army (P.J.B. Jr., G.P.G., N.A.K., B.R.W., and C.M.). The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of William Beaumont Army Medical Center, the Department of Defense, or the United States Government. In addition, Dr. Andrew J. Schoenfeld is a Robert Wood Johnson Foundation Clinical Scholar. The Robert Wood Johnson Foundation and the Department of Veterans Affairs were not directly involved in study design, data acquisition and interpretation, or manuscript preparation or review. Any opinions expressed herein do not necessarily reflect the opinions of the Robert Wood Johnson Foundation or the Department of Veterans Affairs. Also, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
J Bone Joint Surg Am. 2014;96:2025-31
d
http://dx.doi.org/10.2106/JBJS.N.00153
2026 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 6-A N U M B E R 24 D E C E M B E R 17, 2 014 d
d
C A R D I A C E V E N T S F O L L O W I N G T O TA L J O I N T A R T H R O P L A S T Y
d
Conclusions: An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and comanagement in the perioperative period for individuals with these risk factors. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
B
oth total knee arthroplasty and total hip arthroplasty are effective for reducing costs associated with treating moderate to severe joint arthritis and improving patient function and quality of life1,2. The number of patients undergoing primary total knee arthroplasty and total hip arthroplasty has increased over the last decade, and the frequency of these arthroplasties is anticipated to rise with an aging population3,4. Cardiac events are major postoperative complications following total knee arthroplasty and total hip arthroplasty5-15. In fact, serious cardiac complications, including myocardial infarction and cardiac arrest, have been reported to account for 7% to 20% of all major systemic complications following total knee arthroplasty and total hip arthroplasty5,16. With the implementation of performance-based outcome metrics in medicine and penalties associated with high readmission rates after elective total knee arthroplasty and total hip arthroplasty17-19, it is imperative to scrutinize patient-based risk factors and surgical risk factors that may influence the development of cardiac complications. Understanding the risk factors can aid in preoperative counseling of the patient, risk optimization, and enhanced observation in the perioperative period. A detailed investigation of preoperative patient-related risk factors is warranted to provide effective medical care in the perioperative setting and to decrease the need for surgical readmissions following primary total joint arthroplasty20. Total knee arthroplasty and total hip arthroplasty are increasingly performed in patients with a greater burden of medical comorbidities, such as diabetes, hypertension, and obesity15,21. However, the effect of individual patient-based risk factors on the development of postoperative cardiac complications remains unknown. If high-risk patients can be identified prior to surgery,
targeted interventions may improve patient outcomes and curtail the healthcare costs associated with unplanned hospital readmission and subsequent morbidity. Previous studies describing adverse postoperative cardiac outcomes following total knee arthroplasty and total hip arthroplasty at tertiary-care facilities may have limited external validity because of sampling from individual centers and from surgeons with extensive experience5,7,9,11,12,16,22,23. The aims of this study were to determine the rates, risk factors, and time of occurrence for cardiac complications at thirty days following surgery, as well as the time of occurrence for deaths, among a large and diverse patient population. The study sample consisted of more than 46,000 patients undergoing either primary unilateral total knee arthroplasty or total hip arthroplasty at any of the numerous medical centers in the U.S. participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Materials and Methods
T
he investigation was approved by our institution’s investigational review board. We utilized the NSQIP data set from 2006 to 2011. The NSQIP and its methodology, including data collection, have been described in detail in 6,24,25 previous publications . The NSQIP data set has also been utilized for 6 similar prognostic research and has been validated as accurate and reliable for these types of studies. The NSQIP methodology has been carefully examined, with specific attention to case collection, data-set handling, and inter-rater 25 reliability, with disagreement rates on variables approaching 1.6% . Patient information is prospectively entered in the current version of NSQIP from more than 480 hospitals in the U.S., and thirty-day postoperative morbidity 26 and mortality are carefully monitored and recorded . Institutions involved in the NSQIP multispecialty model that capture data on joint arthroplasty cases must collect and submit data on 20% of their orthopaedic surgical caseload.
TABLE I Cardiac Complications and Patient Deaths* Total Hip Arthroplasty (N = 17,640)
Total Knee Arthroplasty (N = 28,682)
Odds Ratio (95% CI)
P Value
58 (0.33)
95 (0.33)
0.99 (0.72 to 1.38)
0.965
Myocardial infarction (no. of events)
43
75
0.93 (0.64 to 1.36)
0.713
Cardiac arrest requiring CPR (no. of events)
21
28
0.82 (0.47 to 1.44)
0.492
61 (0.35)
53 (0.18)
1.87 (1.30 to 2.71)
0.001
Outcome All adverse cardiac events (no. of patients) (%)
Death (no. of patients) (%)
*In the thirty-day perioperative period, 167 major cardiac complications were recorded in 153 patients within the entire total hip arthroplasty and total knee arthroplasty cohort. CI = confidence interval, and CPR = cardiopulmonary resuscitation.
2027 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 6-A N U M B E R 24 D E C E M B E R 17, 2 014 d
d
C A R D I A C E V E N T S F O L L O W I N G T O TA L J O I N T A R T H R O P L A S T Y
d
TABLE II Results of Bivariate Analyses for the Influence of Risk Factors on the Development of Adverse Cardiac Events Postoperatively* Total Knee Arthroplasty Characteristic Age (yr)
Odds Ratio (95% CI)
Total Hip Arthroplasty P Value
Odds Ratio (95% CI)
P Value
1.08 (1.06 to 1.10)
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Postoperative Myocardial Infarction and Cardiac Arrest Following Primary Total Knee and Hip Arthroplasty: Rates, Risk Factors, and Time of Occurrence Philip J. Belmont Jr., MD, Gens P. Goodman, DO, Nicholas A. Kusnezov, MD, Charles Magee, MD, MPH, Julia O. Bader, PhD, Brian R. Waterman, MD, and Andrew J. Schoenfeld, MD, MSc Investigation performed at William Beaumont Army Medical Center, El Paso, Texas
Background: Cardiac complications are a major cause of postoperative morbidity. The purpose of this study was to determine the rates, risk factors, and time of occurrence for cardiac complications within thirty days after primary unilateral total knee arthroplasty and total hip arthroplasty. Methods: The American College of Surgeons National Surgical Quality Improvement Program data set from 2006 to 2011 was used to identify all total knee arthroplasties and total hip arthroplasties. Cardiac complications occurring within thirty days after surgery were the primary outcome measure. Patients were designated as having a history of cardiac disease if they had a new diagnosis or exacerbation of chronic congestive heart failure or a history of angina within thirty days before surgery, a history of myocardial infarction within six months, and/or any percutaneous cardiac intervention or other major cardiac surgery at any time. An analysis of the occurrence of all major cardiac complications and deaths within the thirty-day postoperative time frame was performed. Results: For the 46,322 patients managed with total knee arthroplasty or total hip arthroplasty, the cardiac complication rate was 0.33% (n = 153) at thirty days postoperatively. In both the total knee arthroplasty and total hip arthroplasty groups, an age of eighty years or more (odds ratios [ORs] = 27.95 and 3.72), hypertension requiring medication (ORs = 4.74 and 2.59), and a history of cardiac disease (ORs = 4.46 and 2.80) were the three most significant predictors for the development of postoperative cardiac complications. Of the patients with a cardiac complication, the time of occurrence was within seven days after surgery for 79% (129 of the 164 patients for whom the time of occurrence could be determined). continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Disclaimers: Some authors are employees of the U.S. Federal Government (A.J.S.) and the United States Army (P.J.B. Jr., G.P.G., N.A.K., B.R.W., and C.M.). The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of William Beaumont Army Medical Center, the Department of Defense, or the United States Government. In addition, Dr. Andrew J. Schoenfeld is a Robert Wood Johnson Foundation Clinical Scholar. The Robert Wood Johnson Foundation and the Department of Veterans Affairs were not directly involved in study design, data acquisition and interpretation, or manuscript preparation or review. Any opinions expressed herein do not necessarily reflect the opinions of the Robert Wood Johnson Foundation or the Department of Veterans Affairs. Also, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
J Bone Joint Surg Am. 2014;96:2025-31
d
http://dx.doi.org/10.2106/JBJS.N.00153
2026 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 6-A N U M B E R 24 D E C E M B E R 17, 2 014 d
d
C A R D I A C E V E N T S F O L L O W I N G T O TA L J O I N T A R T H R O P L A S T Y
d
Conclusions: An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. Consideration should be given to a preoperative cardiology evaluation and comanagement in the perioperative period for individuals with these risk factors. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
B
oth total knee arthroplasty and total hip arthroplasty are effective for reducing costs associated with treating moderate to severe joint arthritis and improving patient function and quality of life1,2. The number of patients undergoing primary total knee arthroplasty and total hip arthroplasty has increased over the last decade, and the frequency of these arthroplasties is anticipated to rise with an aging population3,4. Cardiac events are major postoperative complications following total knee arthroplasty and total hip arthroplasty5-15. In fact, serious cardiac complications, including myocardial infarction and cardiac arrest, have been reported to account for 7% to 20% of all major systemic complications following total knee arthroplasty and total hip arthroplasty5,16. With the implementation of performance-based outcome metrics in medicine and penalties associated with high readmission rates after elective total knee arthroplasty and total hip arthroplasty17-19, it is imperative to scrutinize patient-based risk factors and surgical risk factors that may influence the development of cardiac complications. Understanding the risk factors can aid in preoperative counseling of the patient, risk optimization, and enhanced observation in the perioperative period. A detailed investigation of preoperative patient-related risk factors is warranted to provide effective medical care in the perioperative setting and to decrease the need for surgical readmissions following primary total joint arthroplasty20. Total knee arthroplasty and total hip arthroplasty are increasingly performed in patients with a greater burden of medical comorbidities, such as diabetes, hypertension, and obesity15,21. However, the effect of individual patient-based risk factors on the development of postoperative cardiac complications remains unknown. If high-risk patients can be identified prior to surgery,
targeted interventions may improve patient outcomes and curtail the healthcare costs associated with unplanned hospital readmission and subsequent morbidity. Previous studies describing adverse postoperative cardiac outcomes following total knee arthroplasty and total hip arthroplasty at tertiary-care facilities may have limited external validity because of sampling from individual centers and from surgeons with extensive experience5,7,9,11,12,16,22,23. The aims of this study were to determine the rates, risk factors, and time of occurrence for cardiac complications at thirty days following surgery, as well as the time of occurrence for deaths, among a large and diverse patient population. The study sample consisted of more than 46,000 patients undergoing either primary unilateral total knee arthroplasty or total hip arthroplasty at any of the numerous medical centers in the U.S. participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Materials and Methods
T
he investigation was approved by our institution’s investigational review board. We utilized the NSQIP data set from 2006 to 2011. The NSQIP and its methodology, including data collection, have been described in detail in 6,24,25 previous publications . The NSQIP data set has also been utilized for 6 similar prognostic research and has been validated as accurate and reliable for these types of studies. The NSQIP methodology has been carefully examined, with specific attention to case collection, data-set handling, and inter-rater 25 reliability, with disagreement rates on variables approaching 1.6% . Patient information is prospectively entered in the current version of NSQIP from more than 480 hospitals in the U.S., and thirty-day postoperative morbidity 26 and mortality are carefully monitored and recorded . Institutions involved in the NSQIP multispecialty model that capture data on joint arthroplasty cases must collect and submit data on 20% of their orthopaedic surgical caseload.
TABLE I Cardiac Complications and Patient Deaths* Total Hip Arthroplasty (N = 17,640)
Total Knee Arthroplasty (N = 28,682)
Odds Ratio (95% CI)
P Value
58 (0.33)
95 (0.33)
0.99 (0.72 to 1.38)
0.965
Myocardial infarction (no. of events)
43
75
0.93 (0.64 to 1.36)
0.713
Cardiac arrest requiring CPR (no. of events)
21
28
0.82 (0.47 to 1.44)
0.492
61 (0.35)
53 (0.18)
1.87 (1.30 to 2.71)
0.001
Outcome All adverse cardiac events (no. of patients) (%)
Death (no. of patients) (%)
*In the thirty-day perioperative period, 167 major cardiac complications were recorded in 153 patients within the entire total hip arthroplasty and total knee arthroplasty cohort. CI = confidence interval, and CPR = cardiopulmonary resuscitation.
2027 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 9 6-A N U M B E R 24 D E C E M B E R 17, 2 014 d
d
C A R D I A C E V E N T S F O L L O W I N G T O TA L J O I N T A R T H R O P L A S T Y
d
TABLE II Results of Bivariate Analyses for the Influence of Risk Factors on the Development of Adverse Cardiac Events Postoperatively* Total Knee Arthroplasty Characteristic Age (yr)
Odds Ratio (95% CI)
Total Hip Arthroplasty P Value
Odds Ratio (95% CI)
P Value
1.08 (1.06 to 1.10)
