Abstract
Background
Cardiac arrest (CA) has been identified as a potential complication following Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). This retrospective, case-controlled study aims to identify risk factors in order to improve the management of patients undergoing THA or TKA with known preoperative comorbidities.
Methods
CPT codes were used to investigate the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified as having cardiac arrest (CA) by the NSQIP guidelines. Patient samples with all possible covariates were included for the multivariate logistic regression analysis and assessed for independent association.
Results
Patients receiving perioperative transfusion, experiencing dyspnea with moderate exertion, dyspnea at rest, patients currently on dialysis, and patients aged ≥72 are all independently associated with increased rates of cardiac arrest (CA) following THA. Patients receiving perioperative transfusion, patients with anemia, bleeding disorders, dyspnea with moderate exertion, cardiac comorbidities, pulmonary comorbidities, and patients aged ≥73 are all associated with increased rates of cardiac arrest (CA) following TKA.
Conclusion
Patients with the identified risk factors are at a greater risk of suffering cardiac arrest within 30 days following THA and TKA. It is imperative that we recognize which risk factors may precipitate CA in THA and TKA recipients so that prophylactic management can be employed. Furthermore, management guidelines should be updated for patients at high risk of CA following THA and TKA to prevent this complication.
Keywords: Total hip arthroplasty, Total knee arthroplasty, Post-operative cardiac arrest, Risk factors, NSQIP
1. Introduction
Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are among the most common elective surgeries in the U.S. with more than 7 million Americans living with a replaced hip or knee.1 It is estimated that over 600,000 knees and 370,000 hips are replaced in the United States annually. The prevalence of TKA and THA is expected to rise significantly as new minimally invasive procedures arise.2,3
TKA and THA procedure growth is projected to increase by 673% and 174% respectively by 2030, equating to a yearly estimate of 4 million total joint arthroplasties (TJA) in the U.S.4 TJAs are popular treatment plans for osteoarthritis patients due to the low risk of postsurgical complications. Still, the rising prevalence of TJA procedures requires efforts to further decrease adverse outcomes. Specifically, postoperative cardiac complications are a significant cause of death amongst TJA patients with a reported 30-day cardiac-related mortality of 0.35% in THA and 0.18% of TKA patients.5 Identification of clear risk factors for postoperative cardiac complications like CA stands to improve outcomes, decrease patient mortality, improve patient risk counseling, and decrease costs.
The mean age for TKA and THA is 64.9 and 65.9 years respectively.1 Patients in this age group are more likely to have other chronic conditions that may influence postoperative outcomes. Although a concrete list of risk factors has yet to be established, several studies implicate increasing age, pre-existing cardiac comorbidities, and hypertension as predictors of adverse cardiac outcomes in TJA patients. To our knowledge, no studies have investigated risk factors for patients who experienced CA only. By doing so we are including all inciting events that may lead to CA, including MI and arrhythmia. The direct link between preoperative states of patients to a single, all inclusive, cardiac complication may help identify new risk factors for cardiac complications, strengthen the associations between existing risk factors for cardiac complications, and may also lead to improved treatment response times and safety of TJA procedures.
The purpose of our study was to identify which risk factors preceded CA. We hypothesized that patients with a history of pulmonary disease, obesity, and cardiac comorbidities undergoing TKA and THA would be more susceptible to developing CA when compared to those without this history.
2. Methods
2.1. Data collection
Data was analyzed from The American College of Surgery National Quality Improvement (NSQIP) Database from 2010 to 2017. This database includes information from over 500 hospitals in the United States.6,7 The database collects a wide variety of demographic, preoperative, intraoperative, and postoperative information about each patient enrolled. Follow up time is 30 days for each patient in the database. Current Procedural Terminology (CPT) codes were used to identify patients who underwent primary THA (27130) or primary TKA (27447) from this database. TKA and THA patients who experienced cardiac arrest, as determined by the original care team, were provided in the NSQIP database and were selected for further analysis.
Cardiac arrest (CA) was defined as the absence of cardiac rhythm or presence of chaotic cardiac rhythm, intraoperatively or within 30 days following surgery, which results in cardiac arrest requiring the initiation of chest compressions. Patients included experienced pulseless VT or Vfib in which defibrillation is performed and PEA arrests requiring chest compressions. Patients who received open cardiac massage are also included. Patients with automatic implantable cardioverter defibrillator that triggered fire with no loss of consciousness were excluded.
Patients who experienced cardiac arrest following THA or TKA were included and assessed for independent association with the following preoperative and perioperative characteristics: age, BMI, operative time, sex, current dialysis, dyspnea with moderate exertion, dyspnea at rest, admission quarter, cardiac comorbidities, pulmonary comorbidities, steroid or immunosuppressant use, diabetes mellitus with oral agents or insulin, cigarette smoking status within the last year, preoperative loss of blood requiring transfusion of red blood cells (RBCs) within 72 h before surgery, anemia, bleeding disorders, platelet count less than 150,000, and perioperative transfusion of RBCs within 72 h after the beginning of the operation. Age, BMI, admission quarter, and operative time were stratified according to Table 1.
Table 1.
Stratifications for patients who experienced Cardiac Arrest following Total Joint Arthroplasty
| Total Knee Arthroplasty (TKA) |
Total Hip Arthroplasty (THA) |
||
|---|---|---|---|
| Risk Factor | Ranges | Risk Factor | Ranges |
| Age | 18-60, 60–67, 67–73, or 73+ | Age | 18-57, 57–65, 65–72, or 72+ |
| BMI | <18.5, 18.5–24.9, 24.9–29.9, or 29.9+ | BMI | <18.5, 18.5–24.9, 24.9–29.9, or 29.9+ |
| Admission Quarter | 1, 2, 3, or 4 | Admission Quarter | 1, 2, 3, or 4 |
Stratification for Age, BMI (Body Mass Index), Admission quarter, and Operative time for association with cardiac arrest following THA and TKA.
Cardiac comorbidities were defined as a history of any of the following: chronic heart failure, myocardial infarction, angina, hypertension requiring medication, percutaneous intervention including stent placement, or previous cardiac surgery. Pulmonary comorbidities were defined as a history of ventilator dependency or history of severe COPD. Bleeding disorders were defined as the presence of any chronic, persistent, or active condition that places the patient at risk for excessive bleeding (e.g., vitamin K deficiency, hemophilia, thrombocytopenia, chronic anticoagulation therapy that has not been discontinued prior to surgery). Anemia was defined as less than 36% preoperative hematocrit in women and less than 39% preoperative hematocrit in men. Perioperative transfusion was defined as receiving at least 1 unit of packed or whole red blood cells given from the surgical start time up to and including 72 h postoperatively. Preoperative transfusion was defined as preoperative loss of blood necessitating any at least 1 unit of whole blood/packed red cells transfused during the 72 h prior to surgery start time, including any blood transfused in the emergency room.
2.2. Statistical analysis
A multivariate regression model was used to determine any independent association between cardiac arrest and pre-/perioperative risk factors. Odds ratios (OR) and 95% confidence intervals (CI) were reported to measure the association between cardiac arrest and risk factors. In order to be included in our study, a patient needed data for all of the variables of interest. All analyses were conducted in SAS studio version 3.8.8 Statistical significance was set at p < 0.05.
3. Results
3.1. Total hip arthroplasty
119,096 patients who underwent primary THA that had data points for all of the characteristics of interest were identified. Of this group of patients, 79 (0.066%) experienced CA. The following risk factors from the multivariate analysis were found to be independently associated with cardiac arrest following primary THA (OR>1 and P < 0.05): perioperative transfusion, dyspnea with moderate exertion, dyspnea with rest, dialysis, and age greater than 72. The full results can be found in Table 2.
Table 2.
Multivariate analysis of risk factors for cardiac arrest following primary THA
| Condition | Odds Ratio | 95% CI | P-value |
|---|---|---|---|
| Bleeding disorder | 0.65 | 0.16–2.70 | 0.556 |
| Preoperative Transfusion | 2.96 | 0.35–24.9 | 0.318 |
| Anemia | 1.12 | 0.64–1.95 | 0.697 |
| Platelet <150 k | 0.97 | 0.38–2.45 | 0.951 |
| Operative time 68–86 min | 0.59 | 0.30–1.16 | 0.123 |
| Operative time 86–110 min | 1.00 | 0.56–1.78 | 0.989 |
| Operative time >110 min | 0.79 | 0.42–1.46 | 0.447 |
| Admission Quarter 2 | 1.10 | 0.58–2.09 | 0.766 |
| Admission Quarter 3 | 1.03 | 0.55–1.96 | 0.917 |
| Admission Quarter 4 | 1.12 | 0.59–2.10 | 0.732 |
| Perioperative transfusion | 2.69 | 1.50–4.81 | <0.001 |
| Age 57-65 | 1.75 | 0.77–3.97 | 0.184 |
| Age 65-72 | 1.36 | 0.56–3.34 | 0.496 |
| Age 72+ | 3.76 | 1.70–8.30 | 0.001 |
| Diabetes | 1.29 | 0.73–2.29 | 0.386 |
| Dyspnea with Moderate Exertion | 2.10 | 1.03–4.30 | 0.041 |
| Dyspnea at Rest | 6.71 | 1.46–30.7 | 0.014 |
| Cardiac Comorbidities | 1.75 | 0.99–3.09 | 0.056 |
| Dialysis | 4.73 | 1.03–21.7 | 0.046 |
| Steroid/Immunosuppressant use | 1.38 | 0.55–3.49 | 0.496 |
| BMI <18.5 | 2.38 | 0.54–10.5 | 0.252 |
| BMI 24.9–29.9 | 0.71 | 0.37–1.38 | 0.313 |
| BMI 29.9+ | 1.03 | 0.56–1.91 | 0.918 |
| Male Sex | 1.34 | 0.84–2.12 | 0.218 |
| Pulmonary Comorbidities | 1.38 | 0.61–3.14 | 0.441 |
| Smoking status | 0.89 | 0.41–1.93 | 0.766 |
Multivariate Analysis of Preoperative and Perioperative Risk Factors for cardiac arrest following Primary Total Hip Arthroplasty (THA).
3.2. Total knee arthroplasty
189,327 patients who underwent primary TKA that had data for all of the preoperative characteristics of interest were identified. Of this group, 143 (0.076%) experienced cardiac arrest. The following preoperative risk factors from the multivariate analysis were found to be independently associated with CA following primary TKA (OR>1 and P < 0.05): bleeding disorders, anemia, perioperative transfusion, dyspnea with moderate exertion, cardiac comorbidities, pulmonary comorbidities, and age greater than 73. The full results can be found in Table 3. Preoperative blood transfusions and dyspnea at rest are not reported in the table because they had an odds ratio and confidence interval of 0. This is because no patients with these comorbidities experienced cardiac arrest following TKA.
Table 3.
Multivariate analysis of risk factors for cardiac arrest following primary TKA
| Condition | Odds Ratio | 95% CI | P-value |
|---|---|---|---|
| Bleeding disorder | 2.05 | 1.06–3.98 | 0.034 |
| Anemia | 2.08 | 1.42–3.05 | <0.001 |
| Platelet <150 k | 0.97 | 0.50–1.88 | 0.927 |
| Operative time 70–86 min | 0.80 | 0.51–1.26 | 0.337 |
| Operative time 86–107 min | 0.78 | 0.49–1.22 | 0.273 |
| Operative time >107 min | 0.77 | 0.49–1.21 | 0.260 |
| Admission Quarter 2 | 0.65 | 0.40–1.06 | 0.085 |
| Admission Quarter 3 | 0.77 | 0.48–1.22 | 0.261 |
| Admission Quarter 4 | 1.06 | 0.69–1.63 | 0.778 |
| Perioperative transfusion | 3.03 | 1.90–4.83 | <0.001 |
| Age 60-67 | 1.41 | 0.80–2.49 | 0.239 |
| Age 67-73 | 1.67 | 0.94–2.96 | 0.082 |
| Age 73+ | 2.58 | 1.50–4.45 | <0.001 |
| Diabetes | 1.11 | 0.75–1.64 | 0.599 |
| Dyspnea with Moderate Exertion | 1.66 | 1.01–2.72 | 0.046 |
| Cardiac Comorbidities | 1.57 | 1.00–2.47 | 0.048 |
| Dialysis | 4.05 | 0.97–16.9 | 0.055 |
| Steroid/Immunosuppressant use | 1.17 | 0.54–2.52 | 0.689 |
| BMI <18.5 | 4.74 | 0.60–37.4 | 0.140 |
| BMI 24.9–29.9 | 1.81 | 0.58–2.42 | 0.650 |
| BMI 29.9+ | 1.69 | 0.86–3.32 | 0.127 |
| Male Sex | 1.23 | 0.87–1.73 | 0.246 |
| Pulmonary Comorbidities | 3.74 | 2.31–6.05 | <0.001 |
| Smoking status | 0.76 | 0.38–1.54 | 0.453 |
Multivariate Analysis of Preoperative and Perioperative Risk Factors for cardiac arrest following Primary Total Knee Arthroplasty (TKA). Preoperative blood transfusions and dyspnea at rest are not reported in the table because they had an odds ratio and confidence interval of 0. This is because no patients with these comorbidities experienced cardiac arrest following TKA.
4. Discussion
Optimization of TJA patient management can help mitigate the risk of complications during surgical interventions. The vast majority of studies do not look at CA alone and instead include it as part of their definitions of MI. It is unclear whether the risk factors for each of these undesired outcomes in our patients are the same, but identification of risk factors for all cardiac complications is clinically relevant when considering the recent call to action for orthopedic surgeons to implement a multidisciplinary approach that values collaboration with other medical specialists for patient optimization.9 Although cardiac clearance teams should provide cardiac work-up, recognizing specific risk factors for CA may streamline preoperative interventions and interprofessional strategies. Overall, implementation of a screener that optimizes a patient’s fitness for THA or TKA up until their surgery may improve outcomes.10,11 Here we discuss the preoperative characteristics we found to be notable contributions to CA development through our NSQIP database analysis.
4.1. History of cardiac comorbidities
History of cardiac comorbidities contributed to increased risk of post-operative CA following TKA in our analysis (OR = 1.57, p < 0.05). Our study agrees with current literature that demonstrates patients with a history of chronic heart failure, angina, hypertension requiring medication, percutaneous intervention including stent placement, or previous cardiac surgery are at an increased risk for developing myocardial infarction (MI) following TJA.12 In our analysis, history of cardiac comorbidities lead to an increased risk of CA, including MI and other inciting events.
In our data set a history of cardiac comorbidities is not a statistically significant risk factor for THA (OR = 1.75, p = 0.056). However, given the strong link between cardiac comorbidities and MI following TJA we believe this lack of association is the result of a small sample size. Therefore, cardiac comorbidities should not be removed from the list of risk factors for postoperative CA in THA. Furthermore, links have been previously established, between postoperative cardiac complications and a history of cardiac comorbidities.13 Given our results, we recommend surgical centers to adopt optimization models aimed specifically at improving outcomes in patients with cardiac comorbidities undergoing TJA. Such a model exists and has been proposed by Whilst Walterman and colleagues as a viable resource for this patient population.14 Future studies should focus on evaluation of the effectiveness of these models.
4.2. Perioperative transfusion
Patients who received perioperative infusions of red blood cell packets appear to be at an increased risk for developing CA following TKA (OR = 3.03, p < 0.05) and THA (OR = 2.69, p < 0.05). Our literature search found that perioperative transfusion among patients undergoing TJA led to a higher incidence of cardiac and pulmonary complications.15 Primary concerns surrounding perioperative transfusions focus on immunological reactions and infections.16 Studies also suggest that transfusions are associated with an increased risk for deep venous thromboembolisms and pulmonary embolism.17 It is estimated that 39% of orthopedic procedures requiring blood transfusions are arthroplasties.18 The wide utilization of transfusions and its association with cardiac complications threatens the safety of THA and TKA. Current literature suggests that preoperative erythropoietin therapy may reduce the need for perioperative transfusion,19 thus reducing the risk for cardiac complications and the use of limited quantities of donor blood. Future studies should continue to explore alternative methods to perioperative transfusions that may yield better patient outcomes.
4.3. Dyspnea with moderate exertion
Our data show that patients who experienced dyspnea with moderate exertion prior to TJA were at a significantly increased risk of CA following both THA (OR = 2.10, p < 0.05) and TKA (OR = 1.66, p < 0.05). This finding is expected considering dyspnea can be the result of many cardiac complications including arrhythmia, ischemia, valvular dysfunction, and restrictive heart disease.20 In addition, dyspnea can be a symptom of pulmonary disease, which we also found to be a risk factor for CA following TKA. Dyspnea with moderate exertion is a readily accessible assessment metric that orthopedic surgeons can use to identify at risk patients and thus accurately characterize outlook. Optimization of these patients using exercise may be challenging due to potential limited functional statues of patients. However, perioperative pulmonary rehabilitation (PPR) programs that focus on bronchial hygiene, breathing control, energy conservation techniques, endurance and strength training and nutritional support have shown to be effective at increasing Vo2 max in low exercise tolerant patients undergoing lung resection.21 PPR may be an untapped resource in the optimization of TJA patients with severe dyspnea. We recommend researchers explore PPR and its utility in arthroplasty surgeries.
4.4. Dyspnea with rest
In addition to Dyspnea with moderate excretion, dyspnea with rest was found to be a strong risk factor for CA following THA (OR = 6.71, p < 0.014). Dyspnea at rest can be considered a symptom of more severe cardiopulmonary disease than dyspnea with moderate exertion, and may explain the increased Odds Ratio for CA (6.71 vs 2.10). Patients exhibiting dyspnea with rest appear to be at significant risk of CA following THA, and we believe this finding would be similar in TKA. For our data set, no patients who experienced CA also experienced dyspnea with rest. There is a lack of data rather than a lack of association for this risk factor, and patients experiencing dyspnea with rest should be associated with increased risk for CA following TJA.
4.5. Dialysis
We identified dialysis as an independent risk factor for CA following THA (OR = 4.73, p < 0.05). Dialysis dependence has recently been described as an independent risk factor for adverse events, mortality, intensive care unit use, and longer admission time in patients undergoing TJA in a retrospective multiple cohort analysis.22 The increased risk of CA in these patients may account for some of the adverse events described in that study. The increased risk for CA in dialysis patients undergoing TJA may be attributed to dialysis-related amyloidosis deposition in cardiac tissue.23, 24, 25 Additionally, dialysis is common amongst patients with chronic kidney disease (CKD) and this population is also considered to be high risk for complications in TJA.26 Several studies advise CKD patients undergoing dialysis to consider kidney transplantation prior TJA to minimize complications.27, 28, 29 CKD patients undergoing dialysis reportedly experience a 10-fold higher risk for inpatient mortality than TJA kidney transplant patients.30 Our results coincide with current literature and may serve as another reason towards recommending kidney transplantation for the optimization of CKD patients undergoing TJA. Unfortunately, kidney transplantation is not always possible due to lack of donors and long patient wait lists. Given these barriers, recognition of pertinent risk factors for CA becomes even more critical. Although dialysis as a risk factor for CA was only significant in THA, it was nearly significant as a risk factor in TKA as well (OR = 4.05, p = 0.055). Despite this, dialysis has been shown to be a risk factor for many postoperative complications following TJA previously. Thus, patients on dialysis undergoing TJA should be carefully monitored for adverse cardiac events.
4.6. Bleeding disorders
We identified bleeding disorders as an independent risk factor for CA in TKA (OR = 2.05, p > 0.05). Current literature commonly attributes bleeding disorders to an increased risk for developing surgical site infections following TJA procedures.31 When analyzing current risk stratification tools like the American Society of Anesthesiologist (ASA) classification system, researchers found that high risk index scores coupled with bleeding disorders were among the most significant predictors of readmission and mortality.32 This study has shown an increased association of bleeding disorders with CA. This reinforces what has been found in previous studies and suggests that postoperative CA might account for some of the postoperative readmission and mortality previously found with bleeding disorders.
4.7. Anemia
Anemia (HCT < 39% if Male or <36% if Female) was found to be a significant risk factor for CA following TKA (OR = 2.08, p < 0.001). This finding aligns with existing literature in that Anemic patients had a higher rate of complications (OR = 2.11), namely cardiovascular following TJA.33 Furthermore, anemia was found to be a risk factor for a range of complications and increased perioperative blood transfusion rates.34 Given that perioperative blood transfusion is also a risk factor for CA, this may account for some of the increase in cardiac complications following TKA. Studies have demonstrated that treating anemia with Iron with or without erythropoietin decreases the need for blood transfusions and may improve patient outcomes.34 However, erythropoietin is not without its own side effects and its use should be decided on an individual basis. We suggest that anemic patients should have their anemia corrected before surgery, and/or be placed under strict monitoring parameters to avoid CA.
4.8. Pulmonary comorbidities
Pulmonary comorbidities were found to be statistically significant predictors of CA in patients undergoing TKA (OR = 3.74, p < 0.05). COPD has been previously characterized as an independent risk factor for Pneumonia, infection, MI, and CA.35, 36, 37 One such study specifically identifies CA as a complication. Our data serves to reinforce the link between pulmonary comorbidities and CA following TKA. Further action is warranted for the management of patients with pulmonary comorbidities undergoing TKA.
4.9. Age
Patients aged 72+ and 73+ were at higher risk for developing CA in THA and TKA respectively (OR = 3.76, p ≤ 0.001) and (OR = 2.58, p < 0.001). This finding is in agreement with previous studies38,39 and unfortunately is not a modifiable risk factor. However, scientific unanimity on the subject of age is reassuring and helps quantify patient risk. Overall, patients aged 72+ should be monitored carefully for cardiogenic complications. Healthcare teams should have CA interventions readily available in anticipation of adverse events.
5. Conclusion
We have identified a comprehensive list of independent preoperative risk factors for post-surgical cardiac arrest (CA) following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Originally, we hypothesized pulmonary disease, obesity, and cardiac comorbidities would be independent risk factors for CA, and our study partially validates this. Pulmonary and cardiac comorbidities were found to be independent risk factors for CA following TKA. Interestingly, obesity was not a statistically significant risk factor for CA following THA (OR = 1.03, P = 0.918) or TKA (OR = 1.69, p = 0.127). This retrospective case controlled study allowed us to look at many different risk factors for postoperative CA at the same time. Using the NSQIP database for our study also allowed us to accurately identify risk factors for CA following TJA despite its relative rarity in practice. Further, our study only identifies risk factors that correlate with increased rates of CA. It does not definitively explain causation for the increase in post-operative CA. Further research is needed to physiologically justify each risk factor for postoperative CA. Additionally, further studies can help develop a preoperative scoring system like the Goldman index to further elucidate the preoperative risk of CA in patients with multiple risk factors. Despite this, our study presents an opportunity to improve the safety of arthroplasty procedures by implementing preoperative screens that take into consideration these characteristics to better estimate a patient’s risk for CA following TJA. Future studies should not only investigate the association between these risk factors and CA but also aim to investigate the pathogenesis of cardiac arrest in the context of each of the risk factors described above in order to optimize patient outcomes following THA or TKA.
Declaration of competing interest
None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Footnotes
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Contributor Information
Rahul Kataria, Email: rkatar2@uic.edu.
Reniell Iniguez, Email: rinigu2@uic.edu.
Michael Foy, Email: mfoy3@uic.edu.
Anshum Sood, Email: anshumsood@gmail.com.
Mark E. Gonzalez, Email: hand15@uic.edu.
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