BOSTON, Massachusetts—Patients who undergo revision or bilateral joint arthroplasty are at significantly higher increased risk for heart attack or heart failure than patients who undergo their first replacement of a single knee or hip, according to new research in Arthritis & Rheumatism.¹

“Clinicians can use this information to better estimate the risk of cardiovascular complications following total joint replacement surgery and, ultimately, to prevent and better manage these complications,” conclude researchers led by Jeffrey N. Katz, MD, director of the orthopaedic and arthritis center for outcomes research at Brigham and Women's Hospital in Boston.

Age, prolonged joint surgery increase cardiovascular risk

In the new case-control study of patients who had undergone total knee or hip replacement surgery at New England Baptist Hospital between November 1, 2001, and March 31, 2004, there were 209 such patients who experienced myocardial infarction, congestive heart failure, unstable angina, arrhythmia, symptomatic hypertension, or pulmonary embolism while in the hospital recovering and 209 matched-controls who did not have cardiac events.
 
The patients had a mean age of 71; 55% of them were female, and 96% were Caucasian. Of the total joint replacement surgeries performed, 80% were primary procedures and 20% were revisions. Overall, 51% were knee replacement surgeries and 49% were hip replacement surgeries.

The study found that advancing age, a history of cardiac problems, revision surgery, and bilateral surgery increased risk of cardiac complications following arthroplasty. Specifically, being age ≥75 was associated with a nearly 2-fold increased risk of cardiac complications following joint replacement surgery, even though controls were matched with cases for age in broad categories. Moreover, a history of arrhythmia increased the risk nearly 3-fold.

Revision surgery was associated with a 2-fold increased cardiac risk. Bilateral joint replacement surgery was associated with a 3.5-fold increased risk, the study showed. "Revision joint replacement and bilateral surgery are much more prolonged operations than primary unilateral joint replacement [and] these findings suggest an increased risk with more prolonged surgery," the researchers wrote.

Translating research into practice

"The study highlights a major concern [that] orthopaedic surgeons have when scheduling total joint replacement procedures,” Jessy Sekhon, MD, an orthopaedic surgeon at Plancher Orthopaedics & Sports Medicine, with offices in New York City and Greenwich, Connecticut.

“Preoperatively, we always spend time discussing with the patient that arthritis?while…disabling and limiting?is not a life threatening condition, [whereas] cardiovascular events can be,” he told MSKreport.com. “As part of the informed consent process, we disclose that major cardiovascular and cardiopulmonary events are…risk[s] of the procedure and that the severity of pain and activity limitation should reach a point where they outweigh, in the patient's perspective, the potential risks of the surgery.” Overall, however, total joint replacement is a very successful procedure, he said.

“To help minimize the occurrence of these untoward events, every patient must receive a cardiac/medical clearance from [his/her] internist or cardiologist,” Dr. Sekhon said. “Adding perioperative beta blockers, cutting out risk factors such as smoking and improving glucose control in diabetics, all help to medically optimize the patient, [and] regional hypotensive anesthesia is now widely employed as well to improve patient cardiovascular outcome.”
 
Orthopaedic surgeons take into account the fact that there is a higher incidence of cardiovascular events following revision total joint replacement and bilateral procedures prior to scheduling these cases. “Revision procedures tend to be in older patients who may already be in a higher risk category because of more advanced preexisting cardiac conditions,” he said. “In addition, just as in bilateral procedures, the operative times tend to be longer with more blood loss and possibly more potential exposure to cement implantation with its concomitant induction of fat emboli. As such, some surgeons may tend to dissuade the patient from bilateral total joint replacement if they have more advanced, or higher number of cardiac risk factors.”

Similarly, Dr. Sekhon said, “meticulous preoperative planning is imperative in a revision total joint replacement to proceed with the surgery expeditiously to decrease exposure to prolonged anesthesia and blood loss.”

Reference

1. Basilico FC, Sweeney G, Losina E, et al. Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum. 2008; 58:1915-1920.