Management of Femoral Neck Fracture in Patients with Triple Vessel Disease and Reduced Ejection Fraction

Introduction to Coronary Revascularization

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide Class I evidence (Level A) that coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 3-vessel disease, with survival benefit being greater when left ventricular ejection fraction is less than 0.50 1, 2

Rationale for Coronary Revascularization Priority

• Patients with triple vessel disease and reduced ejection fraction (less than 50%) have a substantially elevated perioperative cardiac risk for orthopedic surgery, making preoperative revascularization a Class I indication 1, 2, 3
• Surgical revascularization (CABG) or PCI in three-vessel disease with EF <50% demonstrates clear survival advantage over medical management alone 1, 2

Recommended Revascularization Strategy

• The American College of Cardiology recommends CABG as the preferred revascularization method for patients with TVD and reduced EF, as it provides superior long-term outcomes compared to PCI in this anatomic and functional context 1, 2, 5
• If PCI is chosen, the American College of Cardiology recommends using bare-metal stents (BMS) followed by 4-6 weeks of dual antiplatelet therapy before proceeding to fracture surgery 1, 2

Timing Algorithm

• After CABG, allow 7-14 days for surgical recovery and hemodynamic stabilization before proceeding with femoral neck fracture repair 7, 8
• If PCI with BMS is performed, maintain dual antiplatelet therapy for 4-6 weeks before stopping clopidogrel 5 days before fracture surgery 1, 2, 7, 8

Management of the Femoral Neck Fracture During Waiting Period

• Provide adequate analgesia to minimize sympathetic stress, and optimize medical management including beta-blockers, statins, and ACE inhibitors 4, 9

Critical Pitfalls to Avoid

• Do not proceed directly to fracture surgery without addressing the TVD and reduced EF, as perioperative cardiac mortality would be unacceptably high 1, 2, 4
• Do not use drug-eluting stents if PCI is chosen, as the 12-month dual antiplatelet requirement would create an impossible clinical dilemma 1, 2

Special Consideration for Unstable Cardiac Status

• If the patient develops unstable angina, acute heart failure, or significant arrhythmias, coronary revascularization becomes emergent 2, 4, 6