ARTYKUŁ SPECJALNY / STATE-OF-THE-ART REVIEW

Cardioorthopedics — is it necessary in clinical practice? A study of patients with hip replacement surgery

Paweł Łęgosz1, Anna E. Platek2, 3, Tim N. Board4, Filip M. Szymański2

1Department of Orthopaedics and Traumatology, Medical University of Warsaw, Warsaw, Poland
21st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
3Department of General and Experimental Pathology with Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
4The Centre for Hip Surgery, Wrightington Hospital, Wigan, United Kingdom

Address for correspondence:
Paweł Łęgosz, MD, PhD, Department of Orthopaedics and Traumatology, Medical University of Warsaw, ul. Lindleya 4, 02–005 Warszawa, Poland,
e-mail: p.legosz@gmail.com
Received: 27.03.2017 Accepted: 29.03.2017

Paweł Łęgosz, MD, PhD is a consultant orthopaedic and trauma surgeon, Chief of the Joint Replacement Unit, and Assistant Professor in the Department of Orthopaedics and Traumatology of the Infant Jesus Teaching Hospital Medical University of Warsaw, Poland. Doctor Łęgosz has vast experience in primary and revision hip replacements and specialises in minimally invasive hip arthroplasty, which is pictured as a less traumatic and more patient friendly approach. His practice encompasses both young and old patients. Being a keen sportsman and recognised expert Paweł Łęgosz has been responsible in recent years for the medical care of internationally renowned Polish famous sportsmen. Doctor Łęgosz’s scope of procedures include: primary total hip replacement, revision hip replacement, surgical treatment of periprosthetic femoral fractures after total hip replacement, etc. As an assistant professor at the Medical University of Warsaw, lecturing on degeneration of joints and hip replacements, he shares his expertise with students and many Polish orthopaedic surgeons in training.

Anna E. Płatek, MD is following her PhD programme at the 1st Department of Cardiology, Medical University of Warsaw, Poland. She is strongly associated with the Cardiovascular Disease Prevent­ion Lab by the 1st Department of Cardiology, but she also works in the Department of General and Experimental Pathology with the Centre for Preclinical Research and Technology (CEPT) by the Medical University of Warsaw, where she pursues here interest in cardiac physiology and bench-side research. She is a recipient of several Scientific Awards of the Rector of the Medical University of Warsaw and a reward of the Polish Academy of Sciences. She has completed numerous research internships in Belgium, Italy, and Portugal. Her projects are focused on the application of preclinical risk assessment and novel cardiovascular risk factors in cardiovascular risk stratification.

Tim Board, BSc (Hons), MB ChB (Hons), MSc (Orth Eng), MRCS, FRCS (Orth), MD is a consultant orthopaedic surgeon at Wrightington Hospital (United Kingdom) and specialises in all aspects of hip surgery, from hip arthroscopy to complex revision. He undertook Fellowship training in Sydney, Hannover, and Wrightington. He is Clinical Director of the Lower Limb Department. He is an Honorary Professor and has numerous research collaborations with the Universities of Manchester, Leeds, and Salford. His is research advisor to the NHS Bone Bank and Associate Editor for Hip International.

Associate Professor Filip M. Szymański, MD, PhD is the head of the Cardiovascular Disease Prevention Lab by the 1st Department of Cardiology, Medical University of Warsaw, Poland. He is a recipient of the Scientific Award of Club 30 of the Polish Cardiac Society (PCS), Award of the President of the PCS, Award of the Polish Hypertension Society, several Scientific Awards of the Rector of the Medical University of Warsaw, and two Club 30 grants from the PCS. His projects are focused on novel cardiovascular risk factors in non-classical, high-risk populations. His research includes thromboembolic risk stratification in atrial fibrillation patients, and its association with obstructive sleep apnoea. His discoveries resulted in the description and introduction into clinical practice of a novel clinical entity — OSAFED syndrome.

INTRODUCTION

It is increasingly common in orthopaedic practice to be faced with patients with both multiple comorbidities and polypharmacy. Therefore, knowledge of possible drug and disease interactions is increasingly important for those assessing the fitness of such patients for surgery, in both the elective and emergency setting.

Among all non-communicable diseases, cardiovascular disease (CVD) is the leading cause of death worldwide [1]. It is estimated that in Europe, CVD accounts for nearly half of all deaths [2]. Therefore, cardiovascular risk factors must be taken into account when planning surgery. Recently published guidelines from the European Society of Cardiology (ESC) for the perioperative management of patients undergoing non-cardiac surgery provide useful data and help to organise management in many groups of patients [3]. Guidelines indicate that the perioperative risk of complications is related to the incidence of comorbidities before surgery, as well as the urgency, extent, type, and duration of surgery. Cardiac complications can occur particularly in patients with documented or asymptomatic ischaemic heart disease, left ventricular dysfunction, valvular heart disease, and cardiac arrhythmias, who undergo surgical procedures associated with prolonged haemodynamic load and strain on the heart. However, these guidelines do not contain sufficient information on how patients undergoing individual types of procedures, especially orthopaedic procedures, should be dealt with. Orthopaedic surgeries are often a great challenge and are a huge burden for patients, especially the elderly with multiple comorbidities. Therefore, a multidisciplinary approach combining orthopaedic surgeons and cardiologists is extremely important in ensuring patient safety in the perioperative period.

HIP SURGERY IN THE MODERN WORLD

Altogether, the annual number of major operations is calculated to include about 4% of the world population [4]. Assuming that the frequency of such operations is the same in Europe, where the total population exceeds 500 million people, the estimated number of major operations is around 19 million per year. Probably, many of these operations are performed in patients with low cardiovascular risk; however, ESC data show that 30% of patients undergoing surgery have concomitant CVD [3]. This means that there are 5.7 million operations of this type every year. These surgeries are associated with high complication rates — an average of 7–11% per annum, and mortality 0.8–1.5% [5]. More importantly, 42% of these problems are caused by cardiovascular complications [6].

Currently, one of the most frequently performed types of surgery is orthopaedic surgery, especially joint arthroplasty of hip or knee. Hip replacements were developed in the 1960s. They constituted a major breakthrough in orthopaedic surgery. Today, after many years of development, it has become one of the most successful operations for improving quality of life.

Complications following total hip replacement are quite rare. However, due to the increasing number of surgical procedures and the relatively high average age of the patients, the overall numbers of complications are increasing. During the first 5–9 years, patients after arthroplasty are at lower cardiovascular mortality risk compared with the control cohort. However, the risk in the arthroplasty cohort increases over time and is higher than in the general population after 8.8 years [7].

Some important complications of hip and knee replacement are:

• — venous thromboembolism;
• — pulmonary embolism;
• — infection of the operated joint;
• — complications of transfusion.

Surgeries in the field of hip and knee replacement are recognised interventions effectively limiting severe pain in patients with advanced degenerative changes in the joints. Epidemiological studies suggest that there is a constantly increasing demand for this type of treatment [8]. It is estimated that in the United States of America in 2030 there will be a 673% increase in the number of hip replacement procedures and a 174% increase in knee replacements [8]. Currently, there are about 320 centres in Poland performing endoprosthetic surgery. According to data provided by the National Health Fund, in 2015, 46,685 hip joint replacements were performed, of which 37,126 were total endoprosthesis, 8898 were partial endoprosthesis, and 661 were repair procedures. The majority of patients were elderly people aged 60–69 years. Primary hip replacement surgery was performed in patients aged 6–106 years; in 50% of cases, the age of the patient was less than 69 years [9]. Orthopaedic surgeries concerning the knee and hip joints are interventions with respectively low (< 1%), and intermediate (1–5%) risk of sudden death or a myocardial infarction within 30 days after treatment, but certain patients may be at high risk [10]. Patients undergoing this surgery are usually elderly with restricted physical activity because of pain in the joints, and as a result are at increased risk of CVD. Moreover, quoting one of the authors of a recent review on this subject “hip fracture is one of the most common orthopaedic conditions that requires hospital admission and is associated with significant morbidity and mortality”. The annual incidence of hip fracture was estimated to be 1.66 million worldwide in 1990 and is expected to reach 6.26 million by 2050 due to the aging population [11]. The majority of hip fractures occur in geriatric patients: approximately 80% of women and 50% of men with hip fractures are aged ≥ 70 years [12].

THE IMPORTANCE OF CARDIOVASCULAR RISK IN ORTHOPAEDIC PATIENTS

Cardiovascular disease causes more than 4 million deaths a year in Europe, which represents 45% of the total number of deaths. In 2015, ischaemic heart disease and cerebrovascular disease were the most common causes of cardiovascular death, accounting for 1.8 million and 1.0 million deaths, respectively. The number of deaths from CVD in recent years has been higher in women (2.2 million) than in men (1.8 million), accounting for 49% of all deaths among women and 40% of all deaths in men. Statistical data show that in this group, the total number of deaths from coronary heart disease is similar among men and women, and the differences between the sexes stem from a greater number of women dying from cerebrovascular disease and other diseases of the cardiovascular system [13].

Early identification of the factors responsible for the development of CVD cannot only effectively prevent the occurrence of CVD, but also afford better control of disease and potential resolution. One of the first large-scale studies to identify risk factors for CVD was the Framingham Heart Study.

In 1948 the Framingham Heart Study was initiated under the direction of the National Heart Institute (now known as the National Heart, Lung, and Blood Institute, or NHLBI) — an ambitious medical research project, which has changed the face of medicine. At the time, little was known about the general causes of heart disease and stroke, but mortality from CVD has been continuously growing since the beginning of the 19th century and has gradually taken on an epidemic scale [14]. Over the years, careful monitoring of the population of Framingham study led to the identification of the main risk factors for diseases of the cardiovascular system such as — high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity. It has also provided valuable information on the impact on CVD associated factors, such as triglycerides or low-density lipoprotein-cholesterol, age, gender, and psychosocial issues. In the last half century, the study resulted in the publication of about 1200 articles in leading medical journals. The concept of identification of risk factors for CVD is now an integral part of a modern medical programme, which has led to the development of effective strategies for the treatment and prevention commonly used in clinical practice. The Framingham Heart Study continues to have a significant impact on the scientific world by increasing diagnostic capabilities based on research outcomes. New diagnostic technologies, such as echocardiography, carotid ultrasound, magnetic resonance imaging of the heart and brain, computed tomography of the heart, and bone densitometry, were included in past and current research protocols.

The factors of cardiovascular risk described above were recently evaluated in a prospective study of patients treated with joint arthroplasty. The Cardiovascular Risk Assessment ScHeme in JOINT arthroplasty study (CRASH-JOINT) revealed the relatively high prevalence of both classical as well as non-classical cardiovascular risk factors in patients undergoing total hip or knee replacement, and showed that those factors are more common than in the general population [15]. In the study, we found that out of 98 patients, eight patients were excluded from the study and surgery, mainly due to cardiac causes. The mean age of the study population was 63.7 ± 12.2 years, and 62.2% were females. Fifty (55.6%) patients were diagnosed with arterial hypertension in the past, ten (11.1%) patients had diabetes mellitus, two (2.2%) had a history of myocardial infarction, and family history of CVD was present in 24 (26.7%) cases. Mean body mass index (BMI) was 28.0 ± 5.1 kg/m2 and 39 (43.3%) patients were overweight, while 28 (31.1%) were obese. These findings are consistent with others presented in epidemiological papers (Fig. 1).

 

Figure 1. Prevalence of comorbidities in patients scheduled for orthopaedic surgery (based on data from: Baker PN, Salar O, Ollivere BJ, et al. BMJ Open 2014; 4: e004405. doi: 10.1136/bmjopen-2013-004405); CVD — cardiovascular disease

METHODS FOR CARDIOVASCULAR RISK EVALUATION

Cardiovascular assessment is crucial when taking care of patients in the orthopaedic department in order to avoid complications. As was mentioned previously [15], the occurrence of cardiac complications after surgery depends on the risk factors of the patient and the type of operation [16]. Each operation triggers a stress response that is initiated by tissue damage, developed with the participation of neuroendocrine factors, and may cause a sympathetic imbalance resulting in myocardial oxygen consumption increase, and an imbalance between prothrombotic factors and fibrinolytic factors. Factors such as duration of the procedure, position of the patient, changes in body temperature, and type of anaesthesia contribute to the haemodynamic stress for the patient. Pathogenesis of cardiovascular and orthopaedic association are shown in Figure 2.

 

Figure 2. Relationship between cardiovascular and orthopaedic disease (modified after: Fisher A, Srikusalanukul W, Davis M, et al. Clin Interv Aging. 2013; 8: 239–256. doi: 10.2147/CIA.S38856); CKD — chronic kidney disease

It may explain why CVD remains one of the main causes of death in the perioperative period (Fig. 3).

 

Figure 3. Cause of death during non-cardiac surgery (modified after: Khan MA, Hossain FS, Ahmed I, et al. Int Orthop. 2013; 37: 2119–2124, doi: 10.1007/s00264-013-2068-1); TIA — transient ischaemic attack

Effective strategies for reducing the risk of cardiac complications in the perioperative period should include assessment of cardiac risk factors, carried out by interviews before surgery. The extent of preoperative cardiac evaluation must be tailored to the patient’s clinical condition, age, and the urgency of the operation [15]. Preoperative cardiac assessment, as recommended by the American and European Heart Associations [17, 18], enables improved cardiac treatment and reduction of cardiac complications. However, despite the high incidence of cardiac disease [19] and dehydration in these patients [20], there is often a reluctance to perform preoperative cardiac investigations such as echocardiography or to utilise intensive perioperative monitoring, due to the urgency of surgery and advanced patient age [21].

Currently, we have several clinical tools that ease the cardiac assessment of patients. They include the Revised Cardiac Risk Index (RCRI) or MICA calculator derived from the National Surgical Quality Improvement Plan [NSQIP] [22]. The newer ACS-NSQIP calculator includes 20 patient risk factors in addition to the surgical procedure:

• — Surgery-specific risk (RCRI and NSQIP). The reported rate of cardiac death or non-fatal myocardial infarction is more than 5% in high-risk procedures, between 1% and 5% in intermediate-risk procedures, and less than 1% in low-risk procedures. Institutional and/or individual surgeon experience with the procedure may increase or lower the risk. Emergency surgery is associated with a particularly high risk; cardiac complications are two to five times more likely than with elective procedures;
• — History of ischaemic heart disease (RCRI);
• — History of heart failure (RCRI);
• — History of cerebrovascular disease (RCRI);
• — Insulin dependent diabetes mellitus (RCRI);
• — Preoperative serum creatinine ≥ 2.0 mg/dL (RCRI) or > 1.5 mg/dL (NSQIP);
• — Increasing age (NQSIP);
• — American Society of Anaesthesiologist class (NSQIP);
• — Preoperative functional status (NSQIP).

Another tool is based on the scheme presented in Figure 4.

 

Figure 4. Cardiac evaluation and care algorithm for semi-urgent hip repair (after: Siu CW, Sun NC, Lau TW, et al. Osteoporos Int. 2010; 21: S587–S591, doi: 10.1007/s00198-010-1393-0)

ADVANTAGES GAINED BY MODIFYING CARDIOVASCULAR RISK IN ORTHOPAEDIC PATIENTS

All the above-mentioned algorithms should be introduced into clinical practice because of the potential advantages of treatment of CVD. First of all, it was shown that cardiovascular risk factors themselves contribute to the development of hip fractures. In a cohort of 31,936 Swedish patients it was shown that the hazard ratio (HR) of hip fracture after a diagnosis of heart failure was 4.40 (95% confidence interval [CI] 3.43–5.63); after a stroke, the HR was 5.09 (95% CI 4.18–6.20); after a diagnosis of peripheral atherosclerosis, the HR was 3.20 (95% CI 2.28–4.50); and after an ischaemic heart disease event, the HR was 2.32 (95% CI 1.91–2.84) [23].

It was also proven that treatment and modification of those risk factors improves patients’ prognosis. For example, in a recent study concerning 39,938 patients with and without hypertensive treatment, who experienced a primary hip fracture [24], the risk of hip fracture was decreased among people exposed to the majority of hypotensive drugs, including thiazides, beta-blockers, calcium channel blockers, and angiotensin II receptor blockers. The protective associations were stronger among exposed men than among exposed women for all drugs except loop diuretics. These results can be associated also with accelerated healing and lower risk of reoperation.

Other risk factors, including thromboembolism, were also reduced following treatment of cardiovascular risk factors. In a study under the acronym PEP [25], it was shown in a multi-centre group of 13,356 patients undergoing surgery for hip fracture that treatment with 160 mg of daily aspirin started preoperatively and continued for 35 days was associated with reductions in pulmonary embolism of 43% (95% CI 18–60; p = 0.002) and in symptomatic deep-vein thrombosis of 29% (95% CI 3–48; p = 0.03). Hence, there is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.

In a study summing up enhanced clinical pathway (CP) of pre-surgery screening, it was shown that implementation of such assessment resulted in nine (1%) patients in the CP group experiencing postoperative congestive heart failure, compared with 37 (5%) control patients (p < 0.001). Postoperative cardiac arrhythmias were significantly lower in the CP group than in the control group (8 [1%] vs. 36 [5%]; p < 0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p < 0.001). Therefore, the effect of changing trends in medical care resulted in improved prognosis of patients.

CONCLUSIONS

In summary, orthopaedic surgeries, in particular total hip and knee replacement, represent a growing burden of medical care and are associated with an increasingly aged an morbid population. Early surgery may reduce in-hospital, short-term, and long-term morbidity and mortality, but it can only be performed along with prompt cardiac assessment and minimisation of unnecessary delays for cardiac clearance. Close collaboration between cardiologists and orthopaedic surgeons is needed in order to facilitate ideal patient management.

Conflict of interest: none declared

References

1. 1. Bloom DE, Cafiero ET, Jane-Llopis E, et al. The global economic burden of noncommunicable diseases. World Economic Forum, Geneva; 2011.
2. 2. Nichols M, Townsend N, Scarborough P, et al. Cardiovascular disease in Europe: epidemiological update. Eur Heart J. 2013; 34(39): 3028–3034, doi: 10.1093/eurheartj/eht356, indexed in Pubmed: 24014390.
3. 3. Kristensen SD, Knuuti J, Saraste A, et al. Authors/Task Force Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014; 35(35): 2383–2431, doi: 10.1093/eurheartj/ehu282, indexed in Pubmed:25086026.
4. 4. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008; 372(9633): 139–144, doi: 10.1016/S0140-6736(08)60878-8, indexed in Pubmed: 18582931.
5. 5. Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009; 360(5): 491–499, doi: 10.1056/NEJMsa0810119, indexed in Pubmed: 19144931.
6. 6. Devereaux PJ, Chan MTV, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012; 307(21): 2295–2304, doi: 10.1001/jama.2012.5502, indexed in Pubmed: 22706835.
7. 7. Gordon M, Rysinska A, Garland A, et al. Increased Long-Term Cardiovascular Risk After Total Hip Arthroplasty: A Nationwide Cohort Study. Medicine (Baltimore). 2016; 95(6): e2662, doi: 10.1097/MD.0000000000002662, indexed in Pubmed: 26871792.
8. 8. Patel A, Pavlou G, Mújica-Mota RE, et al. The epidemiology of revision total knee and hip arthroplasty in England and Wales: a comparative analysis with projections for the United States. A study using the National Joint Registry dataset. Bone Joint J. 2015; 97-B(8): 1076–1081, doi: 10.1302/0301-620X.97B8.35170, indexed in Pubmed: 26224824.
9. 9. http://www.aotm.gov.pl/www/wp-content/uploads/2016/08/ AOTMiT_WT_553_14_2015_endoprotezoplastyka_kompleksowa_raport.pdf.
10. 10. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J. 2014; 35(35): 2383–2431, doi: 10.1093/eurheartj/ehu282.
11. 11. Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992; 2(6): 285–289, indexed in Pubmed: 1421796.
12. 12. Lauritzen JB, Schwarz P, Lund B, et al. Changing incidence and residual lifetime risk of common osteoporosis-related fractures. Osteoporos Int. 1993; 3(3): 127–132, indexed in Pubmed: 8481588.
13. 13. Townsend N, Wilson L, Bhatnagar P, et al. Cardiovascular disease in Europe 2016: an epidemiological update. Eur Heart J. 2016; 37(42): 3182–3183, doi: 10.1093/eurheartj/ehw468.
14. 14. http://www.framinghamheartstudy.org/about-fhs/history.php.
15. 15. Łęgosz P, Kotkowski M, Platek AE, et al. Assessment of cardiovascular risk in patients undergoing total joint alloplasty: the CRASH-JOINT study. Kardiol Pol. 2017; 75(3): 213–220, doi: 10.5603/KP.a2016.0162, indexed in Pubmed: 27878804.
16. 16. Mangano DT. Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth. 2004; 18(1): 1–6, indexed in Pubmed: 14973791.
17. 17. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116(17): 1971–1996, doi: 10.1161/CIRCULATIONAHA.107.185700, indexed in Pubmed: 17901356.
18. 18. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009; 30(22): 2769–2812, doi: 10.1093/eurheartj/eht431, indexed in Pubmed: 19713421.
19. 19. Matot I, Oppenheim-Eden A, Ratrot R, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology. 2003; 98(1): 156–163, doi: 0000542-200301000-00025, indexed in Pubmed: 12502992.
20. 20. Knight R. A response to ‘A study of the initial fluid resuscitation and pain management of patients with fractured neck of femur’, Levy N, Anaesthesia 2002; 57: 1148. Anaesthesia. 2003; 58(4): 403–404, doi: 10.1046/j.1365-2044.2003.03132_1.x, indexed in Pubmed: 12648149.
21. 21. Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur. Anaesthesia. 2008; 63(3): 250–258, doi: 10.1111/j.1365-2044.2007.05328.x, indexed in Pubmed: 18289230.
22. 22. https://www.uptodate.com/contents/evaluation-of-cardiac- risk-prior-to-noncardiac-surgery.
23. 23. Ruths S, Bakken MS, Ranhoff AH, et al. Risk of hip fracture among older people using antihypertensive drugs: a nationwide cohort study. BMC Geriatr. 2015; 15: 153, doi: 10.1186/s12877-015-0154-5, indexed in Pubmed: 26626043.
24. 24. Beaupre LA, Cinats JG, Senthilselvan A, et al. Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway. Qual Saf Health Care. 2006; 15(5): 375–379, doi: 10.1136/qshc.2005.017095, indexed in Pubmed: 17074877.
25. 25. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet. 2000; 355(9212): 1295–1302, doi: 10.1016/S0140-6736(00)02110-3, indexed in Pubmed: 10776741.

 

Cite this article as: Łęgosz P, Platek AE, Board TN, Szymański FM. Cardioorthopedics — is it necessary in clinical practice? A study of patients with hip replacement surgery. Kardiol Pol. 2017; 75(8): 729–735, doi: 10.5603/KP.2017.0151.