Alest

作者：Terry Hartnett  
出處：WebMD醫學新聞

　　April 13, 2010 (華盛頓特區) — 研究者在「醫院醫學會(SHM)年會：2010醫院醫學年會」中報告指出，需要手術治療髖骨骨折的75歲以上病患，鬱血性心衰竭的臨床發生率較高，結果也比沒有髖骨骨折者差。
　　
　　明尼蘇達州羅徹斯特梅約診所住院總醫師Michael Cullen建議與會聽眾，應由住院病患專責醫師與其他照護者密切注意相關警訊，如心律不整，以預防病患發生不佳的結果。
　　
　　Cullen醫師在海報展示中發表他們的人口基礎研究發現。
　　
　　Cullen醫師在會中接受Medscape Internal Medicine訪問時表示，發生髖骨骨折的年長病患，術後心衰竭風險遠高於較年輕的病患。
　　
　　Cullen醫師表示，髖骨骨折手術之前即已經有心臟病的病患，術後心衰竭風險增加，使用藥物治療術前心衰竭、心律不整與其他心臟狀況，也會造成髖骨手術之後的心衰竭比率較高。
　　
　　Cullen醫師表示，這些病患會迅速發生心臟代償失調，因此需要密切監測，他們往往還有其他許多影響因素：共病症、創傷本身的壓力、手術的壓力；這些因素增加了此類病患的嚴重風險。
　　
　　在該研究中，Cullen醫師等人試圖確認髖骨骨折之後導致心衰竭風險增加的因素，特別是術後7天。他表示，發現這個風險是重要的，因為心衰竭事件可能會嚴重限制術後恢復與復健，導致較長的住院天數以及不佳的整體結果。
　　
　　Cullen醫師與梅約診所的研究夥伴回顧了明尼蘇達州Olmsted郡、在4年間、所有65歲以上、曾經進行髖骨骨折手術、病患的病歷，他們追蹤了1212名術後病患，為期1年，如果病患在追蹤期間發生第二次髖骨骨折，視為另一個案例研究。
　　
　　該研究發現，術後心衰竭的累積發生率為21.3% (95%信心區間[CI]為18.8%- 23.7%)，術後心衰竭比率顯著高於術前心衰竭比率(風險比為3.0；95% CI，2.3%- 3.9%；P< .001)，住院死亡率風險遠高於那些發生早期術後心衰竭者(風險比為4.7；95% CI，2.4%- 9.0%；P< .001)。
　　
　　研究者注意到一些可能的心衰竭預測因子，並將它們和術後發生的事件比較。發生最多術後心臟事件的是75歲以上病患(229例事件)，其次依序為高血壓(157例事件)、心絞痛(108例事件) 、心房纖維顫動(94例事件)、曾經心臟病發作(86例事件)、以及腦血管疾病(85例事件)，85歲以上病患有134例事件。
　　
　　導致發生較多事件的術前心臟方面用藥包括阿斯匹靈(89例事件)、亨利氏環利尿劑(84例事件)、血管收縮素轉化酶抑制劑或血管張力素受器阻斷劑(69例事件)、鈣離子通道阻斷劑(54例事件)、以及毛地黃(54例事件)。
　　
　　降低術後心衰竭發生率的因素，包括手術之前6個月至5年完成冠狀動脈繞道手術、肝病、心臟傳導完全阻塞、節律器以及使用thiazide利尿劑。Cullen醫師表示，心衰竭的風險因素，特別是那些發生在需要髖骨骨折手術之前的因素，必須在術前和術後都給予密切注意與監測。
　　
　　加州Santa Clara、Kaiser Permanente醫療團體住院病患專責醫師、SHM Board委員Janet Nagamine醫師表示，本研究的結果指出，越來越需要外科醫師(本案例中的骨科醫師)和住院病患專責醫師共同處置。
　　
　　Nagamine醫師向Medscape Internal Medicine表示，SHM已經發展一套新版的外科共同處置方案，住院病患專責醫師在術前、術中、術後探視病患。
　　
　　Nagamine醫師已經擔任SHM品質與安全委員會主席達7年，認為此研究是以共同處置策略改善品質與安全的典型範例。
　　
　　該研究並未接受商業補助，Cullen醫師與 Nagamine醫師皆宣告沒有相關財務關係。
　　
　　醫院醫學會(SHM)年會：2010醫院醫學年會」：摘要41。發表於2010年4月9日。


Older Patients With Hip Fractures at Increased Risk for Heart Failure

By Terry Hartnett
Medscape Medical News

April 13, 2010 (Washington, DC) — Patients older than 75 years who need surgery to repair a hip fracture have a critically higher incidence of congestive heart failure and a significantly worse outcome than their counterparts without hip fractures, researchers reported here at Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting.

Warning signs such as arrhythmia should be monitored closely by hospitalists and other healthcare providers to prevent poor patient outcomes, Michael Cullen, MD, chief medical resident at the Mayo Clinic in Rochester, Minnesota, advised meeting attendees.

Dr. Cullen presented the findings of a population-based study he and his colleagues conducted here during a poster session.

"Elderly patients who have a hip fracture have a much higher risk for postoperative heart failure than younger patients," Dr. Cullen told Medscape Internal Medicine during an interview at the meeting.

"Patients who have had a cardiac event before the hip fracture surgery are at increased risk of having a heart failure event after surgery," said Dr. Cullen. Use of medications to treat preoperative heart failure, arrhythmias, and other cardiac conditions also lead to higher rates of heart failure following hip surgery.

"These patients can decompensate rapidly and therefore need to be monitored closely," said Dr. Cullen. "They have so many factors against them — comorbidities, the stress of the injury itself, and the stress of surgery; these all add up to create a serious risk to these patients."

In the study, Dr. Cullen and his colleagues sought to determine what factors led to a higher risk for heart failure after hip fracture, particularly in the 7 days after the operation. Addressing this risk is critical, he said, because a heart failure event can severely limit postoperative recovery and rehabilitation, and lead to longer hospital stays and poor overall outcomes.

Dr. Cullen and his colleagues at the Mayo Clinic reviewed the medical records of all patients in Olmsted County, Minnesota, who were older than 65 years and who had undergone hip repair surgery during a 4-year period. They followed 1212 patients postoperatively for 1 year. If a patient had a second hip operation during the follow-up period, it was counted as a separate case study.

The study found that the cumulative rate of postoperative heart failure was 21.3% (95% confidence interval [CI], 18.8%?- 23.7%). Rates of postoperative heart failure were significantly higher among those with preoperative heart failure (hazard ratio, 3.0; 95% CI, 2.3%?- 3.9%; P?< .001). Risk for inpatient mortality was much higher in those who developed early postoperative heart failure (odds ratio, 4.7; 95% CI, 2.4%?- 9.0%; P?< .001).

The investigators looked at a number of possible predictors of heart failure and compared them with events that occurred after surgery. The highest number of postoperative cardiac events was for patients older than 75 years (229 events), followed by those with hypertension (157 events), angina (108 events), atrial fibrillation (94 events), a previous heart attack (86 events), and cerebrovascular disease (85 events). Patients older than 85 years had 134 events.

The medications given before surgery for cardiac conditions that led to the highest number of incidents were aspirin (89 events), loop diuretics (84 events), angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (69 events), calcium channel blockers (54 events), and digoxin (54 events).

The factors that led to a low incidence of heart failure postoperatively included coronary revascularization done 6 months to 5 years before the operation, liver disease, complete heart block, pacemaker, and the use of thiazide diuretics.

Dr. Cullen said that risk factors for heart failure, particularly those that occur before the need for hip fracture surgery, must be given closer attention and monitoring both before and after surgery.

The results of this study point to the growing need for the comanagement of surgical patients between the surgeon (in this case, the orthopaedist) and the hospitalist, said Janet Nagamine, MD, a member of the SHM Board, and a hospitalist at Kaiser Permanente Medical Group in Santa Clara, California.

Dr. Nagamine told Medscape Internal Medicine that SHM has developed a new initiative for surgical comanagement. The hospitalist sees the patient pre-, peri-, and postoperatively, she said.

Dr. Nagamine served as head of the SHM quality and safety committee for 7 years, and said this study is a classic example of how quality and safety can be improved with a comanagement strategy.

The study did not receive commercial support. Dr. Cullen and Dr. Nagamine have disclosed no relevant financial relationships.

Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting. Abstract?41. Presented April?9, 2010.