Myocardial injury in hip fractures: a HIP ATTACK-1 randomized trial substudy

Abstract Background Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the myocardial injury. Purpose To determine if accelerated surgery is superior to standard-care on the 90-day risk of vascular outcomes and death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme at hospital arrival. Methods The HIP ATTACK-1 trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard-care in reducing death or major complications. This substudy includes 1392/2970 patients with a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality, myocardial infarction, stroke, and congestive heart failure at 90-days after randomization. Results 322/1392 (23%) patients had a troponin elevation at hospital arrival. Among patients with troponin elevation, median time from hip fracture diagnosis to surgery was 6 h (IQR 5–13) in the accelerated-care group and 29 h (IQR 19–52) in the standard-care group. Patients with an increased troponin had lower risk of mortality with accelerated surgery compared to standard-care (17/163 [10%] versus 36/159 [23%]; HR 0.43 [95% CI 0.24–0.77]); and lower risk of the composite outcome (23/163 [14%] versus 47/159 [30%]; HR 0.43 [CI 95% 0.26-0.72]). Conclusion One in 5 patients with hip fracture present with myocardial injury. Accelerated surgery demonstrated a lower risk of mortality and major cardiovascular outcomes compared with standard-care.