In patients with hip fracture and an elevated troponin level, rapid surgical intervention was associated with lower mortality.

In the HIP ATTACK trial (NEJM JW Gen Med Mar 15; 2020 and Lancet 2020; 395: 698-708), nearly 3000 patients who presented with hip fracture after low-energy trauma (e.g. ground-level fall) were randomised to undergo either accelerated surgery (i.e. within six hours) or standard-timing surgery (i.e. within 24 hours). Results showed marginal benefits in some secondary outcomes for accelerated surgery. Investigators have performed a substudy of the original trial data – focusing on the nearly 1400 patients for whom cardiac troponin tests were ordered at hospital arrival for hip fracture. The goal was to determine if timing of surgery affected outcomes in patients with elevated troponin levels and those with normal troponin levels.

Among patients with elevated arrival troponin levels (nearly one-quarter of patients with measured levels), accelerated surgery was associated with significantly lower mortality than was standard surgery (10% vs 23%; number needed to treat, eight). Among patients with normal arrival troponin levels, no mortality difference was seen (8% and 9%).

Comment: These impressive results suggest that – despite elevated admission troponin levels – patients had better outcomes when undergoing immediate surgery without further work-up or even a short delay. This new analysis will lead me to order admission troponin levels more systematically for my patients with hip fracture. Using those results to advocate for more-rapid fracture repair in high-risk patients likely will improve outcomes while we await results of the ongoing follow-up study (HIP ATTACK-2), which will determine more definitively if accelerated surgery is superior to standard surgical timing in these patients.

Daniel D. Dressler, MD, MSc, MHM, FACP, Professor of Medicine, Emory University School of Medicine, Atlanta, USA.

Borges FK, et al. Myocardial injury in patients with hip fracture: a HIP ATTACK randomized trial substudy. J Bone Joint Surg Am 2024; 106: 2303-2312.
Cornell C. Patients presenting with acute myocardial injury with hip fracture have greater survival with rapid surgical care. J Bone Joint Surg Am 2024; 106: e50.

This summary is taken from the following Journal Watch titles: General Medicine, Hospital Medicine, Ambulatory Medicine, Emergency Medicine.