Preoperative cardiac abnormalities associated with one-year mortality in elderly patients undergoing hip fracture surgery: The role of focused TTE

Preoperative cardiac abnormalities associated with one-year mortality in elderly patients undergoing hip fracture surgery: The role of focused TTE | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Preoperative cardiac abnormalities associated with one-year mortality in elderly patients undergoing hip fracture surgery: The role of focused TTE Kaihua Fan, Jianwei Zhang, Ying Gao, Weimei Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4806373/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Purpose We sought to identify preoperative cardiac abnormalities associated with postoperative mortality in elderly patients undergoing hip fractures surgery, in order to provide reference for focused transthoracic echocardiography (TTE). Methods In this retrospective study, a total of 669 elderly patients (age over 65 years) undergoing hip fractures surgery were included, of which 58(8.7%) died within one-year after discharge. Cox regression analysis models were used to identify the prognostic cardiac abnormalities of postoperative mortality. Results Univariate analysis showed that age (HR 1.065, 95%CI 1.030–1.101; P < 0.001), ASA score (III, IV vs. I, II) (HR 1.855, 95%CI 1.098–3.067; P = 0.022), history of chronic obstructive pulmonary disease (COPD)(HR 4.446, 95%CI 1.909–10.355; P = 0.001) and atrial fibrillation (AF)(HR 3.803, 95%CI 1.803–8.024; P < 0.001), presence of left ventricular ejection fraction (LVEF) < 50%(HR 5.009, 95%CI 2.151–11.665; P 25mmHg(HR 4.388, 95%CI 2.492–7.725; P < 0.001), moderate-severe aortic valve stenosis (AS) (HR 4.702, 95%CI 1.471–15.035; P = 0.009) were the dominant predictors of mortality within one-year. The presence of LVEF < 50%, left ventricular dilatation and elevated PASP were proved to be the independent predictors of one-year mortality in elderly patients in multivariate analysis. Conclusion Cardiac abnormalities derived from preoperative TTE, namely LVEF < 50%, AS, left ventricular dilatation and elevated PASP had prognostic value for elderly patients undergoing hip fracture surgery. We consider that these indices would be clinically important regarding the preoperative cardiac risk assessment of elderly hip fracture patients who are treated with surgery, which may be assessed in the focused TTE. Health sciences/Health care/Geriatrics Health sciences/Health care/Medical imaging/Ultrasonography/Echocardiography Health sciences/Health care/Fracture repair Health sciences/Medical research/Outcomes research Health sciences/Diseases/Cardiovascular diseases preoperative echocardiography cardiac abnormalities mortality hip fractures elderly patients Figures Figure 1 Figure 2 Introduction Worldwide, the number of individuals with hip fractures is rapidly increasing due to the increasing age of the population. Prior studies documented that most cases who experienced hip fractures were aged 65 years and older. Furthermore, hip fractures in elderly patients is associated with an increased morbidity, mortality, and loss of functional independence, which is becoming a public health burden.[ 1 , 2 ] At present, surgical repair is the standard of care, even for the weak patients. In addition, prompt orthopedic intervention within 48 hours of fractures significantly improved prognosis and reduced mortality.[ 3 , 4 ] Transthoracic echocardiography (TTE) provides a qualitative and quantitative assessment of cardiac morphology and function, helping to diagnose specific cardiac pathologies, such as cardiac failure, aortic stenosis, and hemodynamic status, which cannot be reliably diagnosed through clinical examination.[ 2 ] A systematic review of echocardiography demonstrated that underlying cardiac pathology detected by echocardiography may alter the diagnosis in 17–78% of cases. Therefore, identifying cardiac abnormalities before surgery can improve perioperative management and reduce postoperative morbidity and mortality.[ 5 ] However, there is also evidence that delaying surgery increases postoperative mortality, constraining the time available for pre-operative investigations.[ 6 ] Studies have suggested that preoperative TTE may delay surgical repair, thereby increasing the risk of mortality and complications.[ 7 – 10 ] Focused TTE is a goal-directed, abbreviated form of echocardiography, which enhances bedside clinical evaluation and guides acute medical decisions without delaying surgery. Focused TTE changes diagnosis and management by guiding preoperative intravascular volume replacement, and rationalizing the use of invasive monitoring, vasopressor infusions and planned postoperative intensive care.[ 6 ] But the cardiac abnormalities focused TTE should focused on are not yet clear and unified. We sought to identify prognostic indices for elderly patients after hip fractures surgery by evaluating the relationship between cardiac abnormalities derived from preoperative TTE and postoperative mortality, in order to provide reference for focused TTE. Materials and Methods Study design and patients This retrospective study was based on the data of elderly hip fractures cases aged over 65 years who were admitted at Shanghai Jiao Tong University Affiliated Sixth People’s Hospital between Jun 2019 and August 2022. We screened our hospital electronic database for the patients diagnosed with hip fractures who underwent surgery. Patients with polytrauma, pathological fractures, periprosthetic fractures, history of malignant tumor, and patients without complete medical records or preoperative transthoracic echocardiography (TTE) were excluded. The local ethics committee approved this research. In the process of the study, researchers covered all data confidentiality and compliance with the Declaration of Helsinki. We retrospectively extracted the patients’ impact data without any intervention measures. Data collection Data for all enrolled patients were collected from the electronic medical records of the hospital. The characteristics those were considered were age, gender, fracture type (femoral neck, intertrochanteric or subtrochanteric), American Society of Anesthesiologists (ASA) score, surgery type (total hip arthroplasty, hemiarthroplasty, or proximal femoral nail anti-rotation) and preoperative medical comorbidities including:1) hypertension, 2) coronary artery disease (CAD, either documented previous myocardial infarction, abnormal coronary angiogram or coronary revascularization), 3) chronic obstructive pulmonary disease (COPD, use of bronchodilators or steroids), 4) cerebrovascular disease (embolic, thrombotic or hemorrhagic cerebral event with persistent residual motor, sensory or cognitive dysfunction), 5) diabetes mellitus requiring oral hypoglycemic or insulin therapy, 6) chronic kidney disease (CKD, persistent elevated creatinine or requirement for intermittent peritoneal or hemodialysis), 7) documented atrial fibrillation (AF)[ 7 ]. Preoperative Transthoracic Echocardiography All patients underwent preoperative transthoracic echocardiography (TTE). A detailed data was sorted from echocardiography reports including left ventricular ejection fraction (LVEF), left ventricular wall thickness, left atrial diameter (LAD), left ventricular end diastolic diameter (LVEDD), pulmonary arterial systolic pressure (PASP), valvular heart disease (stenosis, regurgitation or insufficiency), left ventricular outflow tract pressure gradient, pericardial effusion (PE). Major TTE abnormalities were defined as: 1) LV systolic dysfunction (LVEF < 50%); 2)Left ventricular hypertrophy (LVH), defined by ratio of posterior wall/septal thickness 25mmHg; 6)Moderate-severe aortic valve stenosis (AS), defined by a mean pressure gradient > 40mmHg and/or an indexed aortic valvular area < 1cm 2 /m 2 ; 7) Moderate-severe mitral valve stenosis (MS), defined by an indexed mitral valvular area 30mmHg; 10) PE.[ 11 ] Definition of Outcome The outcome was defined as postoperative all-cause mortality within one year after discharge. Verification of death was acquired from hospital databases and telephone follow-up. Statistical Analysis Descriptive statistics (mean and standard deviation [SD] for continuous variables, frequencies, and proportions for categorical variables) were calculated. Continuous data was compared using Student’s t-test, Mann-Whitney U-test, Kruskal-Wallis H-test, and analysis of variance (ANOVA). Categorical data was analyzed using χ2 or Fisher’s exact tests. To assess the association between potential explanatory factors and outcomes, Cox regression analysis was used and hazard ratio (HR) and 95% confidence interval (95% CI) were calculated. For postoperative mortality, a univariate screen was first performed and variables with P-values < 0.001 were subjected to multivariate COX regression model. Final multivariable model was determined using forward selection (LR, Likelihood Ratio) and α = 0.05 significance level. Furthermore, the continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to exactly quantify the number of patients correctly reclassified into higher or lower risk categories after adding cardiac abnormalities to a base model. Receiver operator characteristic (ROC) analysis was performed to examine the predictive performance of models for mortality. Kaplan-Meier curves were used to examine cumulative event rates, and differences between groups were tested using the log rank test. Statistical analysis was carried out using SPSS v.26.0 (SPSS, Chicago, IL) and R-language 4.3.1. A two-sided P < 0.05 was accepted to indicate a statistically significant difference. Results A total of 669 elderly patients with hip fractures surgery between June 2019 and August 2022 were included in our final analysis. The clinical characteristics are shown in Table 1 . Mean age of them were 78.8 (± 8.0) years and 215(32.1%) cases were male. 58 cases of them died within one year after discharge, of which 12 cases (20.7%) died of COVID-19, 7 cases (12.1%) died of cerebrovascular diseases, 7 cases (12.1%) died of Alzheimer's disease, 23 cases (39.6%) died from cardiovascular diseases (8 from heart failure, 10 from arrhythmia, 5 from sudden cardiac death) and 9 cases (15.5%) of unknown causes. Table 1 Baseline Characteristics of elderly Patients undergoing Hip Fracture surgery Variables Total (N = 669) Survival (N = 611) Death (N = 58) P value Age, years 78.8 ± 8.0 78.5 ± 7.9 82.7 ± 8.0 <0.001 65–74 222(33.2) 211(34.5) 11(19.0) 75–84 283(42.3) 260(42.6) 23(39.7) 0.003 ≥ 85 164(24.5) 140(22.9) 24(41.4) Male, n (%) 215(32.1) 199(32.6) 16(27.6) 0.437 Fracture type, n (%) Femoral neck 365(54.6) 334(54.7) 31(53.4) Intertrochanteric 279(41.7) 253(41.4) 26(44.8) 0.798 Subtrochanteric 25(3.7) 24(3.9) 1(1.7) ASA score, n (%) I 58(8.7) 53(8.7) 5(8.6) II 291(43.5) 274(44.8) 17(29.3) 0.093 III 309(46.2) 274(44.8) 35(60.3) IV 11(1.6) 10(1.6) 1(1.7) Surgery type, n (%) Total hip arthroplasty 247(36.9) 227(37.2) 20(34.5) Hemiarthroplasty 114(17.0) 99(16.2) 15(25.9) 0.168 Proximal femoral nail anti-rotation 308(46.0) 285(46.6) 23(39.7) Comorbidities on admission, n (%) Hypertension 316(47.2) 285(46.6) 31(53.4) 0.321 Coronary artery disease 72(10.8) 68(11.1) 4(6.9) 0.320 COPD 20(3.0) 14(2.3) 6(10.3) 0.005 Cerebrovascular disease 90(13.5) 83(13.6) 51(12.1) 0.747 Diabetes 138(20.6) 124(20.3) 14(24.1) 0.489 Chronic kidney disease 18(2.7) 17(2.8) 1(1.7) 1 Atrial fibrillation 30(4.5) 22(3.6) 8(13.8) 0.003 Echocardiographic abnormality, n (%) LVEF 25mmHg 64(9.6) 47(7.7) 17(29.3) < 0.001 Moderate-severe AS 9(1.3) 6(1.0) 3(5.2) 0.036 Moderate-severe MS 1(0.1) 1(0.2) 0(0.0) 1 Moderate-severe aortic or mitral valve regurgitation 11(1.6) 10(1.6) 1(1.7) 1 LVOTO 3(0.4) 2(0.3) 1(1.7) 0.239 PE 4(0.6) 3(0.5) 1(1.7) 0.305 ASA, American society of anesthesiologists; COPD, Chronic obstructive pulmonary disease; TTE, Transthoracic echocardiography; LVEF, Left ventricular ejection fraction; LVH, Left ventricular hypertrophy; PASP, Pulmonary arterial systolic pressure; AS, Aortic valve stenosis; MS, Mitral valve stenosis; LVOTO, Left ventricular outflow tract obstruction; PE, Pericardial effusion The characteristics of patients who died or survived were listed in supplementary table 1 . There were no significant differences in gender, fractures type and surgery type between the survivals and postoperative deaths within one year after discharge. Patients with older age and higher ASA score (III, IV vs. I, II) had a higher mortality. As to comorbidities on admission, patients with history of COPD (P = 0.001) and AF (P < 0.001) had a higher mortality within one year. Patients who died within one year were more likely to have LVEF 25mmHg (29.3% vs. 7.7%, P < 0.001) and moderate-severe AS (5.2% vs. 1.0%, P = 0.036) than those who survived. The following variables were found to be independently associated with mortality within one year in univariate COX regression analysis (Table 2 ): age (HR 1.065, 95%CI 1.030–1.101; P < 0.001), ASA score (III, IV vs. I, II) (HR 1.855, 95%CI 1.098–3.067; P = 0.022), history of COPD (HR 4.446, 95%CI 1.909–10.355; P = 0.001) and AF (HR 3.803, 95%CI 1.803–8.024; P < 0.001), presence of LVEF < 50% (HR 5.009, 95%CI 2.151–11.665; P 25mmHg (HR 4.388, 95%CI 2.492–7.725; P < 0.001), moderate-severe AS (HR 4.702, 95%CI 1.471–15.035; P = 0.009). Supplemental table 1 showed a multivariate COX regression model including all the above factors. The presence of LVEF < 50%, left ventricular dilatation and elevated PASP were proved to be the independent predictors of one-year mortality in elderly patients. Table 2 Univariate COX regression Analysis for the Prediction of Mortality within One Year Variable HR 95%CI P value Age, years 1.065 1.030–1.101 < 0.001 65–74 75–84 1.770 1.248–2.511 0.001 ≥ 85 Male (yes vs. no) 0.797 0.448–1.417 0.440 Fracture type Femoral neck Intertrochanteric 0.961 0.611–1.513 0.865 Subtrochanteric ASA score (III, IV vs. I, II) 1.855 1.092–3.153 0.022 Surgery type Total hip arthroplasty Hemiarthroplasty 0.946 0.713–1.254 0.698 Proximal femoral nail anti-rotation Comorbidities on admission (yes vs. no) Hypertension 1.301 0.776–2.179 0.318 Coronary artery disease 0.607 0.220–1676 0.335 COPD 4.446 1.909–10.355 0.001 Cerebrovascular disease 0.868 0.394–1.912 0.725 Diabetes 1.237 0.678–2.257 0.488 Chronic kidney disease 0.625 0.086–4.511 0.641 Atrial fibrillation 3.803 1.803–8.024 < 0.001 Echocardiographic abnormality (yes vs. no) LVEF < 50% 5.009 2.151–11.665 25mmHg 4.388 2.492–7.725 < 0.001 Moderate-severe AS 4.702 1.471–15.035 0.009 Moderate-severe MS - - 0.840 Moderate-severe aortic or mitral valve regurgitation 1.074 0.149–7.760 0.943 LVOTO 5.129 0.710-37.056 0.105 PE 3.368 0.466–24.328 0.229 HR, hazard ratio; CI, Confidence Interval; ASA, American society of anesthesiologists; COPD, Chronic obstructive pulmonary disease; TTE, Transthoracic echocardiography; LVEF, Left ventricular ejection fraction; LVH, Left ventricular hypertrophy; PASP, Pulmonary arterial systolic pressure; AS, Aortic valve stenosis; MS, Mitral valve stenosis; LVOTO, Left ventricular outflow tract obstruction; PE, Pericardial effusion To avoid the problems of overfitting and collinearity, the aforementioned significant predictors (P < 0.001) (age, AF, LVEF 25mmHg) were included in the multivariate COX regression analysis. Results demonstrated that age (HR 1.049, 95%CI 1.013–1.086; P = 0.007), history of AF (HR 2.510, 95%CI 1.134–5.557; P = 0.023), presence of LVEF 25mmHg (HR 2.687, 95%CI 1.449–4.984; P = 0.002) maintained the predictive value of mortality within one-year (Table 3 ). Moreover, model 1(including age, AF, LVEF 25mmHg) had significantly improved ability to reclassify patients’ risk than model 0 (including age and AF) (IDI = 4.3%, P < 0.001; continuous NRI = 31.4%, P = 0.008). Table 3 Multivariate COX Regression Analysis for The Prediction of Mortality Within One Year Variable HR 95%CI P value Model 0 Age, years 1.059 1.025–1.095 0.001 Atrial fibrillation (yes vs. no) 3.043 1.429–6.478 0.004 Model 1 Age, years 1.049 1.013–1.086 0.007 Atrial fibrillation (yes vs. no) 2.510 1.134–5.557 0.023 Echocardiographic abnormality (yes vs. no) LVEF 25mmHg 2.687 1.449–4.984 0.002 HR, hazard ratio; CI, Confidence Interval; LVEF, Left ventricular ejection fraction; PASP, Pulmonary arterial systolic ROC analysis showed that the area under curves (AUC) of model 1 was greater than that of model 0 (0.726 vs. 0.652, P = 0.008) (Fig. 1 ). Kaplan–Meier analysis demonstrated that patients with older age, history of AF, presence of LVEF 25mmHg had a higher mortality within one-year(Fig. 2 ). Discussion This study found that advanced age, history of AF, COPD were the independent predictive factors of postoperative mortality in elderly patients with hip fractures surgery. Cardiac abnormalities derived from preoperative TTE, apart from LVEF < 50% and AS which were commonly mentioned, left ventricular dilatation, and elevated PASP also had prognostic values for elderly patients undergoing hip fracture surgery. Hip fractures are common in the elderly patients and lead to increased morbidity, mortality, and medical costs[ 12 ]. Timely surgical repair improves outcomes and quality of life in this population. Before surgical repair, preoperative cardiac evaluation must consider the risk-benefit ratio. TTE is a useful non-invasive investigation for screening and assessment of cardiac disease and risk. Several studies have found that preoperative TTE significantly lengthens the time to surgery and does not improve the survival of patients.[ 7 , 9 , 13 ] A retrospective, nationwide cohort study in Japan demonstrated that preoperative echocardiography was not associated with reduced in-hospital mortality or postoperative complications.[ 2 ] In addition, preoperative echocardiography in patients with hip fractures has been found to be associated with increased mortality at 90 days and 1 year.[ 7 , 14 ] But, cardiac abnormality detected by preoperative TTE such as aortic stenosis or left ventricular dysfunction did alter preoperative consultations and targeting invasive monitoring to improve patient outcomes.[ 15 – 17 ] Patients with cardiac abnormality of preoperative TTE did indeed receive different care, which avoids the occurrence of adverse events.[ 18 ] In recent studies, focused TTE was found to be feasible, not to delay surgery and frequently influence diagnosis and management by identifying important cardiac disease and hemodynamic abnormalities.[ 19 , 20 ] However, most of the articles were observational studies with inherent design flaws. A small prospectively randomized study demonstrated that preoperative focused TTE led to important changes in treatment, such as more rational use of invasive monitoring, vasopressor infusion and postoperative intensive care in patients with hip fractures.[ 6 ]At present, the studies on cardiac abnormalities that focused TTE should pay attention to are not comprehensive. A prognostic study of elderly patients with intertrochanteric fractures demonstrated the predictive value of LVEF, AS, and LVEDD for one-month and one-year mortality.[ 13 ] A study in China revealed the predictive value of preoperative TTE for major cardiac events and in-hospital mortality in elderly patients with hip fractures and proposed cardiac abnormalities including LVEF < 50% and AS.[ 21 ] Consistent with previous research, our data confirmed that LVEF < 50% remained predictive value for mortality in aged patients with hip fractures surgery.[ 13 , 15 ] Another preoperative cardiac predictor that increased the mortality in patients undergoing hip fracture surgery is elevated PASP. PASP has been found to be a predictor of in-hospital mortality in elderly patients with hip fractures.[ 1 ] Our study suggested that PASP > 25mmHg is a predictive factor for one-year mortality after adjusting for age, atrial fibrillation and LVEF < 50%. The PASP elevation has been shown to be associated with fat embolism and venous thromboembolism in elderly patients.[ 22 , 23 ] In addition, direct connection between elevated PASP and right ventricular failure has been reported in a prior study. [ 24 ] In addition, we found a patient with left ventricular dilatation had an increased risk of one-year mortality (HR: 3.813, 95% CI: 1.730–8.403, P = 0.001). Increased LVEDD has been correlated with dilated, ischemic, or hypertensive cardiomyopathy, ventricular septal defect, and mitral/aortic regurgitation. Dilated left ventricle with a thinner myocardial wall predisposes heart to diastolic and systolic dysfunction, diminished coronary artery circulation and ventricular dysrhythmias.[ 25 ] Moreover, left ventricular capacity overload can lead to pulmonary edema and lung infection. Our research also found that AS had predictive value for one-year mortality (HR: 4.702, 95% CI: 1.471–15.035, P = 0.009). This may be due to hemodynamic instability. AS resulted in decreased left ventricular compliance and coronary reserve. In our study, the presence of AF was found to be an independent preoperative cardiac risk factor of the in-one-year mortality. AF is the most encountered arrhythmia in clinical practice and its frequency significantly increases with age. Previous studies have shown a close relationship between AF and thromboembolic events, decreased motor ability, depression, and cognitive impairment in elderly patients.[ 1 ]Therefore, it is reasonable that patients with the presence of AF could have a higher risk of worse outcomes and mortality. In addition, our data revealed that history of COPD were associated with an increase in one-year mortality. COPD is known as a risk factor for chronic PASP elevation [ 22 ], which may be the way it increases mortality. Limitation The major limitation is that this study was a single central retrospective analysis, which might be related to selection bias. We minimized the bias in patient enrollment by using data from an electronic medical record database. The patients involved were elderly patients with preoperative TTE, so our results cannot be directly applied to all patients undergoing hip fracture surgery. Further multicenter, prospective studies with larger population are needed to confirm the study’s results. Conclusion Our research suggested that elderly patients undergoing hip fracture surgery with a history of AF and a presence of elevated PASP might require closer follow-up, a careful fluid management and anti-coagulant treatment, even without LVEF < 50% or AS. We consider that these indices including LVEF, AS, LVEDD and PASP would be clinically important regarding the preoperative cardiac risk assessment of elderly hip fracture patients who are treated with surgery, which may be assessed in the focused TTE. Declarations Ethics approval and consent to participate: Ethics committee of shanghai sixth people's hospital approved this research (ethic code number: 2023 − 161). The written informed consent was obtained from all subjects. Our study was conducted in accordance with the principles of the Declaration of Helsinki 1975, as revised in 2008. Consent for publication: Not applicable. Competing interests: The authors report no conflicts of interest in this work. Funding: No funding was received to assist with the preparation of this manuscript. Author Contribution Authors' contributions: WML and YG designed the study and completed the analysis and manuscript. KHF and JWZ helped with data collection and arrangement. 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Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report. Clinical interventions in aging 15, 755–762 (2020). Lam, C. S. P. et al. Age-associated increases in pulmonary artery systolic pressure in the general population. Circulation 119, 2663–2670 (2009). Memtsoudis, S. G., Besculides, M. C., Gaber, L., Liu, S. & Della González Valle, A. Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. International orthopaedics 33, 1739–1745 (2009). Kumar, A. & Neema, P. K. Severe pulmonary hypertension and right ventricular failure. Indian journal of anaesthesia 61, 753–759 (2017). Nadruz, W. Myocardial remodeling in hypertension. Journal of human hypertension 29, 1–6 (2015). Additional Declarations No competing interests reported. Supplementary Files supplementarytable.docx Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 17 Aug, 2024 Editor invited by journal 08 Aug, 2024 Submission checks completed at journal 06 Aug, 2024 First submitted to journal 26 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4806373","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":342115941,"identity":"7d11ad44-77ad-43a1-b2dc-293cf20cfd0f","order_by":0,"name":"Kaihua Fan","email":"","orcid":"","institution":"Shanghai Jiao Tong University Affiliated Sixth People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kaihua","middleName":"","lastName":"Fan","suffix":""},{"id":342115942,"identity":"82532f1e-4cdd-439b-b0c0-f332d21f2b51","order_by":1,"name":"Jianwei Zhang","email":"","orcid":"","institution":"Shanghai Jiao Tong University Affiliated Sixth People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jianwei","middleName":"","lastName":"Zhang","suffix":""},{"id":342115943,"identity":"6c7a8e9f-dbd7-49eb-9d6c-2553530dc43b","order_by":2,"name":"Ying Gao","email":"","orcid":"","institution":"iFlytek Research, iFlytek Co.Ltd","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Gao","suffix":""},{"id":342115944,"identity":"1a4491e3-55d2-4b20-bf8a-41865c3be898","order_by":3,"name":"Weimei Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYBACAxCRUCEhZwDhWhCr5YyFsQEDM4grQaQWxraKxA1gLQzEaJHITnzw4IxE+nb2/qMbfhRIMPC3dycQ0JK72QDol9ydPYfZbvYAHSZx5uwG/Fqkc7dJJJyRyN1wI5ntBg9QC9AQglq2/0hsk0g3AGq5+YdILdsYgFoSQFpuE2eL/NvNIIcZbjhz2Oy2jIEED0G/2Pec3fjxR0WdvMHxxmc33/yxkeNv78WvBQPwkKZ8FIyCUTAKRgFWAABvqEbutezOtgAAAABJRU5ErkJggg==","orcid":"","institution":"Shanghai Jiao Tong University Affiliated Sixth People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Weimei","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-07-26 08:07:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4806373/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4806373/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64385018,"identity":"d1106331-89b5-40fe-bb34-5e3ef8e6174c","added_by":"auto","created_at":"2024-09-12 12:23:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96343,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) analysis of models to predict the mortality within one yearin elderly hip fracture undergoing surgery.\u003c/p\u003e","description":"","filename":"OnlineFIG1.png","url":"https://assets-eu.researchsquare.com/files/rs-4806373/v1/04c167c78bacd05eaf31cd1e.png"},{"id":64385019,"identity":"cf52f885-4ed1-49b3-b447-cb19c773969b","added_by":"auto","created_at":"2024-09-12 12:23:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167917,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier freedom from event curves according to (A) age, (B) atrial fibrillation (AF), (C) left ventricular ejection fraction (LVEF)\u0026lt;50%, and (D) pulmonary arterial systolic pressure (PASP)\u0026gt;25mmHg for the elderly patients after hip fractures surgery.\u003c/p\u003e","description":"","filename":"OnlineFIG2.png","url":"https://assets-eu.researchsquare.com/files/rs-4806373/v1/6ad58f7577c26288072c3238.png"},{"id":64386161,"identity":"6bb014ed-8fb7-47db-8da9-a04405e8a675","added_by":"auto","created_at":"2024-09-12 12:31:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1047057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4806373/v1/812f9315-0963-4c42-b20e-a034ecfb0d50.pdf"},{"id":64385016,"identity":"7c77e2c0-60db-47d0-ab22-b5af8ada1596","added_by":"auto","created_at":"2024-09-12 12:23:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16228,"visible":true,"origin":"","legend":"","description":"","filename":"supplementarytable.docx","url":"https://assets-eu.researchsquare.com/files/rs-4806373/v1/a5a3d163a03d14d7b658c686.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative cardiac abnormalities associated with one-year mortality in elderly patients undergoing hip fracture surgery: The role of focused TTE","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorldwide, the number of individuals with hip fractures is rapidly increasing due to the increasing age of the population. Prior studies documented that most cases who experienced hip fractures were aged 65 years and older. Furthermore, hip fractures in elderly patients is associated with an increased morbidity, mortality, and loss of functional independence, which is becoming a public health burden.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] At present, surgical repair is the standard of care, even for the weak patients. In addition, prompt orthopedic intervention within 48 hours of fractures significantly improved prognosis and reduced mortality.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTransthoracic echocardiography (TTE) provides a qualitative and quantitative assessment of cardiac morphology and function, helping to diagnose specific cardiac pathologies, such as cardiac failure, aortic stenosis, and hemodynamic status, which cannot be reliably diagnosed through clinical examination.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] A systematic review of echocardiography demonstrated that underlying cardiac pathology detected by echocardiography may alter the diagnosis in 17\u0026ndash;78% of cases. Therefore, identifying cardiac abnormalities before surgery can improve perioperative management and reduce postoperative morbidity and mortality.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] However, there is also evidence that delaying surgery increases postoperative mortality, constraining the time available for pre-operative investigations.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Studies have suggested that preoperative TTE may delay surgical repair, thereby increasing the risk of mortality and complications.[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFocused TTE is a goal-directed, abbreviated form of echocardiography, which enhances bedside clinical evaluation and guides acute medical decisions without delaying surgery. Focused TTE changes diagnosis and management by guiding preoperative intravascular volume replacement, and rationalizing the use of invasive monitoring, vasopressor infusions and planned postoperative intensive care.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] But the cardiac abnormalities focused TTE should focused on are not yet clear and unified. We sought to identify prognostic indices for elderly patients after hip fractures surgery by evaluating the relationship between cardiac abnormalities derived from preoperative TTE and postoperative mortality, in order to provide reference for focused TTE.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eThis retrospective study was based on the data of elderly hip fractures cases aged over 65 years who were admitted at Shanghai Jiao Tong University Affiliated Sixth People\u0026rsquo;s Hospital between Jun 2019 and August 2022. We screened our hospital electronic database for the patients diagnosed with hip fractures who underwent surgery. Patients with polytrauma, pathological fractures, periprosthetic fractures, history of malignant tumor, and patients without complete medical records or preoperative transthoracic echocardiography (TTE) were excluded. The local ethics committee approved this research. In the process of the study, researchers covered all data confidentiality and compliance with the Declaration of Helsinki. We retrospectively extracted the patients\u0026rsquo; impact data without any intervention measures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData for all enrolled patients were collected from the electronic medical records of the hospital. The characteristics those were considered were age, gender, fracture type (femoral neck, intertrochanteric or subtrochanteric), American Society of Anesthesiologists (ASA) score, surgery type (total hip arthroplasty, hemiarthroplasty, or proximal femoral nail anti-rotation) and preoperative medical comorbidities including:1) hypertension, 2) coronary artery disease (CAD, either documented previous myocardial infarction, abnormal coronary angiogram or coronary revascularization), 3) chronic obstructive pulmonary disease (COPD, use of bronchodilators or steroids), 4) cerebrovascular disease (embolic, thrombotic or hemorrhagic cerebral event with persistent residual motor, sensory or cognitive dysfunction), 5) diabetes mellitus requiring oral hypoglycemic or insulin therapy, 6) chronic kidney disease (CKD, persistent elevated creatinine or requirement for intermittent peritoneal or hemodialysis), 7) documented atrial fibrillation (AF)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Transthoracic Echocardiography\u003c/h2\u003e \u003cp\u003eAll patients underwent preoperative transthoracic echocardiography (TTE). A detailed data was sorted from echocardiography reports including left ventricular ejection fraction (LVEF), left ventricular wall thickness, left atrial diameter (LAD), left ventricular end diastolic diameter (LVEDD), pulmonary arterial systolic pressure (PASP), valvular heart disease (stenosis, regurgitation or insufficiency), left ventricular outflow tract pressure gradient, pericardial effusion (PE).\u003c/p\u003e \u003cp\u003eMajor TTE abnormalities were defined as: 1) LV systolic dysfunction (LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%); 2)Left ventricular hypertrophy (LVH), defined by ratio of posterior wall/septal thickness\u0026thinsp;\u0026lt;\u0026thinsp;1.1; 3) Left atrial dilatation (LAD\u0026thinsp;\u0026ge;\u0026thinsp;40mm); 4) Left ventricular dilatation (LVEDD\u0026thinsp;\u0026ge;\u0026thinsp;55mm in male; LVEDD\u0026thinsp;\u0026ge;\u0026thinsp;50mm in female); 5) PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg; 6)Moderate-severe aortic valve stenosis (AS), defined by a mean pressure gradient\u0026thinsp;\u0026gt;\u0026thinsp;40mmHg and/or an indexed aortic valvular area\u0026thinsp;\u0026lt;\u0026thinsp;1cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e; 7) Moderate-severe mitral valve stenosis (MS), defined by an indexed mitral valvular area\u0026thinsp;\u0026lt;\u0026thinsp;1cm\u003csup\u003e2\u003c/sup\u003e/m\u003csup\u003e2\u003c/sup\u003e; 8) Moderate-severe aortic or mitral valvular regurgitation; 9) Left ventricular outflow tract obstruction (LVOTO), defined by a peak pressure gradient\u0026thinsp;\u0026gt;\u0026thinsp;30mmHg; 10) PE.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDefinition of Outcome\u003c/h2\u003e \u003cp\u003eThe outcome was defined as postoperative all-cause mortality within one year after discharge. Verification of death was acquired from hospital databases and telephone follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics (mean and standard deviation [SD] for continuous variables, frequencies, and proportions for categorical variables) were calculated. Continuous data was compared using Student\u0026rsquo;s t-test, Mann-Whitney U-test, Kruskal-Wallis H-test, and analysis of variance (ANOVA). Categorical data was analyzed using χ2 or Fisher\u0026rsquo;s exact tests. To assess the association between potential explanatory factors and outcomes, Cox regression analysis was used and hazard ratio (HR) and 95% confidence interval (95% CI) were calculated. For postoperative mortality, a univariate screen was first performed and variables with P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.001 were subjected to multivariate COX regression model. Final multivariable model was determined using forward selection (LR, Likelihood Ratio) and α\u0026thinsp;=\u0026thinsp;0.05 significance level. Furthermore, the continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to exactly quantify the number of patients correctly reclassified into higher or lower risk categories after adding cardiac abnormalities to a base model. Receiver operator characteristic (ROC) analysis was performed to examine the predictive performance of models for mortality. Kaplan-Meier curves were used to examine cumulative event rates, and differences between groups were tested using the log rank test. Statistical analysis was carried out using SPSS v.26.0 (SPSS, Chicago, IL) and R-language 4.3.1. A two-sided P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted to indicate a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 669 elderly patients with hip fractures surgery between June 2019 and August 2022 were included in our final analysis. The clinical characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Mean age of them were 78.8 (\u0026plusmn;\u0026thinsp;8.0) years and 215(32.1%) cases were male. 58 cases of them died within one year after discharge, of which 12 cases (20.7%) died of COVID-19, 7 cases (12.1%) died of cerebrovascular diseases, 7 cases (12.1%) died of Alzheimer's disease, 23 cases (39.6%) died from cardiovascular diseases (8 from heart failure, 10 from arrhythmia, 5 from sudden cardiac death) and 9 cases (15.5%) of unknown causes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of elderly Patients undergoing Hip Fracture surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;669)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvival (N\u0026thinsp;=\u0026thinsp;611)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeath (N\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222(33.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211(34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e260(42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164(24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140(22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215(32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e199(32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e365(54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e334(54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31(53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntertrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e279(41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253(41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.798\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA score, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58(8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53(8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5(8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e291(43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e274(44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e309(46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e274(44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hip arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247(36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e227(37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114(17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99(16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal femoral nail anti-rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e308(46.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e285(46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23(39.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities on admission, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e316(47.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e285(46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31(53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68(11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90(13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83(13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138(20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e124(20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.489\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30(4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiographic abnormality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft atrial dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65(10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricular dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64(9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47(7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe AS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe MS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe aortic or mitral valve regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOTO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eASA, American society of anesthesiologists; COPD, Chronic obstructive pulmonary disease; TTE, Transthoracic echocardiography; LVEF, Left ventricular ejection fraction; LVH, Left ventricular hypertrophy; PASP, Pulmonary arterial systolic pressure; AS, Aortic valve stenosis; MS, Mitral valve stenosis; LVOTO, Left ventricular outflow tract obstruction; PE, Pericardial effusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe characteristics of patients who died or survived were listed in supplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no significant differences in gender, fractures type and surgery type between the survivals and postoperative deaths within one year after discharge. Patients with older age and higher ASA score (III, IV vs. I, II) had a higher mortality. As to comorbidities on admission, patients with history of COPD (P\u0026thinsp;=\u0026thinsp;0.001) and AF (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) had a higher mortality within one year. Patients who died within one year were more likely to have LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% (10.3% vs. 2.1%, P\u0026thinsp;=\u0026thinsp;0.004), left ventricular dilatation (12.1% vs. 3.3%, P\u0026thinsp;=\u0026thinsp;0.006), PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg (29.3% vs. 7.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and moderate-severe AS (5.2% vs. 1.0%, P\u0026thinsp;=\u0026thinsp;0.036) than those who survived.\u003c/p\u003e \u003cp\u003eThe following variables were found to be independently associated with mortality within one year in univariate COX regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e): age (HR 1.065, 95%CI 1.030\u0026ndash;1.101; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ASA score (III, IV vs. I, II) (HR 1.855, 95%CI 1.098\u0026ndash;3.067; P\u0026thinsp;=\u0026thinsp;0.022), history of COPD (HR 4.446, 95%CI 1.909\u0026ndash;10.355; P\u0026thinsp;=\u0026thinsp;0.001) and AF (HR 3.803, 95%CI 1.803\u0026ndash;8.024; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), presence of LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% (HR 5.009, 95%CI 2.151\u0026ndash;11.665; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), left ventricular dilatation (HR 3.813, 95%CI 1.730\u0026ndash;8.403; P\u0026thinsp;=\u0026thinsp;0.001), PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg (HR 4.388, 95%CI 2.492\u0026ndash;7.725; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), moderate-severe AS (HR 4.702, 95%CI 1.471\u0026ndash;15.035; P\u0026thinsp;=\u0026thinsp;0.009). Supplemental table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed a multivariate COX regression model including all the above factors. The presence of LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%, left ventricular dilatation and elevated PASP were proved to be the independent predictors of one-year mortality in elderly patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate COX regression Analysis for the Prediction of Mortality within One Year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.030\u0026ndash;1.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e65\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e75\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.248\u0026ndash;2.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale (yes vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.797\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.448\u0026ndash;1.417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.440\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFracture type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntertrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.611\u0026ndash;1.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtrochanteric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score (III, IV vs. I, II)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.092\u0026ndash;3.153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hip arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.946\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.713\u0026ndash;1.254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.698\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal femoral nail anti-rotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities on admission (yes vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.776\u0026ndash;2.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.607\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.220\u0026ndash;1676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.909\u0026ndash;10.355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.394\u0026ndash;1.912\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.678\u0026ndash;2.257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.086\u0026ndash;4.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.641\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.803\u0026ndash;8.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEchocardiographic abnormality (yes vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.151\u0026ndash;11.665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.088\u0026ndash;4.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft atrial dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.522\u0026ndash;2.534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricular dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.730\u0026ndash;8.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.492\u0026ndash;7.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe AS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.471\u0026ndash;15.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe MS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-severe aortic or mitral valve regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.149\u0026ndash;7.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.943\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVOTO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.710-37.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.466\u0026ndash;24.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHR, hazard ratio; CI, Confidence Interval; ASA, American society of anesthesiologists; COPD, Chronic obstructive pulmonary disease; TTE, Transthoracic echocardiography; LVEF, Left ventricular ejection fraction; LVH, Left ventricular hypertrophy; PASP, Pulmonary arterial systolic pressure; AS, Aortic valve stenosis; MS, Mitral valve stenosis; LVOTO, Left ventricular outflow tract obstruction; PE, Pericardial effusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo avoid the problems of overfitting and collinearity, the aforementioned significant predictors (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (age, AF, LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% and PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg) were included in the multivariate COX regression analysis. Results demonstrated that age (HR 1.049, 95%CI 1.013\u0026ndash;1.086; P\u0026thinsp;=\u0026thinsp;0.007), history of AF (HR 2.510, 95%CI 1.134\u0026ndash;5.557; P\u0026thinsp;=\u0026thinsp;0.023), presence of LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% (HR 3.815, 95%CI 1.577\u0026ndash;9.228; P\u0026thinsp;=\u0026thinsp;0.003) and PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg (HR 2.687, 95%CI 1.449\u0026ndash;4.984; P\u0026thinsp;=\u0026thinsp;0.002) maintained the predictive value of mortality within one-year (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Moreover, model 1(including age, AF, LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% and PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg) had significantly improved ability to reclassify patients\u0026rsquo; risk than model 0 (including age and AF) (IDI\u0026thinsp;=\u0026thinsp;4.3%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; continuous NRI\u0026thinsp;=\u0026thinsp;31.4%, P\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate COX Regression Analysis for The Prediction of Mortality Within One Year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel 0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.025\u0026ndash;1.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation (yes vs. no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.429\u0026ndash;6.478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.013\u0026ndash;1.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation (yes vs. no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.134\u0026ndash;5.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiographic abnormality (yes vs. no)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.577\u0026ndash;9.228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.449\u0026ndash;4.984\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHR, hazard ratio; CI, Confidence Interval; LVEF, Left ventricular ejection fraction; PASP, Pulmonary arterial systolic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eROC analysis showed that the area under curves (AUC) of model 1 was greater than that of model 0 (0.726 vs. 0.652, P\u0026thinsp;=\u0026thinsp;0.008) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Kaplan\u0026ndash;Meier analysis demonstrated that patients with older age, history of AF, presence of LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% and PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg had a higher mortality within one-year(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that advanced age, history of AF, COPD were the independent predictive factors of postoperative mortality in elderly patients with hip fractures surgery. Cardiac abnormalities derived from preoperative TTE, apart from LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% and AS which were commonly mentioned, left ventricular dilatation, and elevated PASP also had prognostic values for elderly patients undergoing hip fracture surgery.\u003c/p\u003e \u003cp\u003eHip fractures are common in the elderly patients and lead to increased morbidity, mortality, and medical costs[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Timely surgical repair improves outcomes and quality of life in this population. Before surgical repair, preoperative cardiac evaluation must consider the risk-benefit ratio. TTE is a useful non-invasive investigation for screening and assessment of cardiac disease and risk. Several studies have found that preoperative TTE significantly lengthens the time to surgery and does not improve the survival of patients.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] A retrospective, nationwide cohort study in Japan demonstrated that preoperative echocardiography was not associated with reduced in-hospital mortality or postoperative complications.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In addition, preoperative echocardiography in patients with hip fractures has been found to be associated with increased mortality at 90 days and 1 year.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] But, cardiac abnormality detected by preoperative TTE such as aortic stenosis or left ventricular dysfunction did alter preoperative consultations and targeting invasive monitoring to improve patient outcomes.[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Patients with cardiac abnormality of preoperative TTE did indeed receive different care, which avoids the occurrence of adverse events.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn recent studies, focused TTE was found to be feasible, not to delay surgery and frequently influence diagnosis and management by identifying important cardiac disease and hemodynamic abnormalities.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] However, most of the articles were observational studies with inherent design flaws. A small prospectively randomized study demonstrated that preoperative focused TTE led to important changes in treatment, such as more rational use of invasive monitoring, vasopressor infusion and postoperative intensive care in patients with hip fractures.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]At present, the studies on cardiac abnormalities that focused TTE should pay attention to are not comprehensive. A prognostic study of elderly patients with intertrochanteric fractures demonstrated the predictive value of LVEF, AS, and LVEDD for one-month and one-year mortality.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] A study in China revealed the predictive value of preoperative TTE for major cardiac events and in-hospital mortality in elderly patients with hip fractures and proposed cardiac abnormalities including LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% and AS.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eConsistent with previous research, our data confirmed that LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% remained predictive value for mortality in aged patients with hip fractures surgery.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Another preoperative cardiac predictor that increased the mortality in patients undergoing hip fracture surgery is elevated PASP. PASP has been found to be a predictor of in-hospital mortality in elderly patients with hip fractures.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Our study suggested that PASP\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg is a predictive factor for one-year mortality after adjusting for age, atrial fibrillation and LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%. The PASP elevation has been shown to be associated with fat embolism and venous thromboembolism in elderly patients.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] In addition, direct connection between elevated PASP and right ventricular failure has been reported in a prior study. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn addition, we found a patient with left ventricular dilatation had an increased risk of one-year mortality (HR: 3.813, 95% CI: 1.730\u0026ndash;8.403, P\u0026thinsp;=\u0026thinsp;0.001). Increased LVEDD has been correlated with dilated, ischemic, or hypertensive cardiomyopathy, ventricular septal defect, and mitral/aortic regurgitation. Dilated left ventricle with a thinner myocardial wall predisposes heart to diastolic and systolic dysfunction, diminished coronary artery circulation and ventricular dysrhythmias.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Moreover, left ventricular capacity overload can lead to pulmonary edema and lung infection. Our research also found that AS had predictive value for one-year mortality (HR: 4.702, 95% CI: 1.471\u0026ndash;15.035, P\u0026thinsp;=\u0026thinsp;0.009). This may be due to hemodynamic instability. AS resulted in decreased left ventricular compliance and coronary reserve.\u003c/p\u003e \u003cp\u003eIn our study, the presence of AF was found to be an independent preoperative cardiac risk factor of the in-one-year mortality. AF is the most encountered arrhythmia in clinical practice and its frequency significantly increases with age. Previous studies have shown a close relationship between AF and thromboembolic events, decreased motor ability, depression, and cognitive impairment in elderly patients.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]Therefore, it is reasonable that patients with the presence of AF could have a higher risk of worse outcomes and mortality. In addition, our data revealed that history of COPD were associated with an increase in one-year mortality. COPD is known as a risk factor for chronic PASP elevation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which may be the way it increases mortality.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThe major limitation is that this study was a single central retrospective analysis, which might be related to selection bias. We minimized the bias in patient enrollment by using data from an electronic medical record database. The patients involved were elderly patients with preoperative TTE, so our results cannot be directly applied to all patients undergoing hip fracture surgery. Further multicenter, prospective studies with larger population are needed to confirm the study\u0026rsquo;s results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur research suggested that elderly patients undergoing hip fracture surgery with a history of AF and a presence of elevated PASP might require closer follow-up, a careful fluid management and anti-coagulant treatment, even without LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50% or AS. We consider that these indices including LVEF, AS, LVEDD and PASP would be clinically important regarding the preoperative cardiac risk assessment of elderly hip fracture patients who are treated with surgery, which may be assessed in the focused TTE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e Ethics committee of shanghai sixth people's hospital approved this research (ethic code number: 2023\u0026thinsp;\u0026minus;\u0026thinsp;161). The written informed consent was obtained from all subjects. Our study was conducted in accordance with the principles of the Declaration of Helsinki 1975, as revised in 2008.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors report no conflicts of interest in this work.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors' contributions: WML and YG designed the study and completed the analysis and manuscript. KHF and JWZ helped with data collection and arrangement. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u0026Ccedil;i\u0026ccedil;ek, V. \u003cem\u003eet al.\u003c/em\u003e Preoperative cardiac risk factors associated with in-hospital mortality in elderly patients without heart failure undergoing hip fracture surgery: a single-centre study. Postgraduate medical journal 97, 701\u0026ndash;705 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYonekura, H. \u003cem\u003eet al.\u003c/em\u003e Preoperative Echocardiography for Patients With Hip Fractures Undergoing Surgery: A Retrospective Cohort Study Using a Nationwide Database. Anesthesia and analgesia 128, 213\u0026ndash;220 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinvani, L. \u003cem\u003eet al.\u003c/em\u003e Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study. Journal of the American Geriatrics Society 68, 1690\u0026ndash;1697 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlestil, T. \u003cem\u003eet al.\u003c/em\u003e Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Scientific reports 8, 13933 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeiberg, J., El-Ansary, D., Canty, D. J., Royse, A. G. \u0026amp; Royse, C. F. Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care. Anaesthesia 71, 1091\u0026ndash;1100 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanty, D. J. \u003cem\u003eet al.\u003c/em\u003e Pilot multi-centre randomised trial of the impact of pre-operative focused cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF-2 pilot). Anaesthesia 73, 428\u0026ndash;437 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang, J. S. \u003cem\u003eet al.\u003c/em\u003e Impact of preoperative echocardiography on surgical delays and outcomes among adults with hip fracture. The bone \u0026amp; joint journal 103-B, 271\u0026ndash;278 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdair, C., Swart, E., Seymour, R., Patt, J. \u0026amp; Karunakar, M. A. Clinical Practice Guidelines Decrease Unnecessary Echocardiograms Before Hip Fracture Surgery. The Journal of bone and joint surgery. American volume 99, 676\u0026ndash;680 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteinberg, E. L. \u003cem\u003eet al.\u003c/em\u003e Financial impact and effect on the outcome of preoperative tests for at-risk older hip fracture patients. Geriatrics \u0026amp; gerontology international 18, 937\u0026ndash;942 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMutlu, H. \u003cem\u003eet al.\u003c/em\u003e The effects of preoperative non-invasive cardiac tests on delay to surgery and subsequent mortality in elderly patients with hip fracture. Journal of back and musculoskeletal rehabilitation 29, 49\u0026ndash;54 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang, R. M. \u003cem\u003eet al.\u003c/em\u003e Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 28, 1\u0026ndash;39.e14 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRostagno, C. \u003cem\u003eet al.\u003c/em\u003e Perioperative Myocardial Infarction/Myocardial Injury Is Associated with High Hospital Mortality in Elderly Patients Undergoing Hip Fracture Surgery. Journal of clinical medicine 9 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalem, M. \u003cem\u003eet al.\u003c/em\u003e Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients. Acta orthopaedica et traumatologica turcica 52, 97\u0026ndash;100 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWijeysundera, D. N. \u003cem\u003eet al.\u003c/em\u003e Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study. BMJ (Clinical research \u003cem\u003eed.)\u003c/em\u003e 342, d3695 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoxdale, S. J., Sneyd, J. R., Donovan, A., Werrett, G. \u0026amp; Viira, D. J. The role of routine pre-operative bedside echocardiography in detecting aortic stenosis in patients with a hip fracture. Anaesthesia 67, 51\u0026ndash;54 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLynes, H. \u0026amp; Griffiths, R. Focused transthoracic echocardiography in hip fracture surgery. Anaesthesia 68, 206\u0026ndash;207 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee, S. H., Han, Y., Kim, S. J., Lee, S. J. \u0026amp; Ryu, Y. J. Impact of right ventricular systolic pressure in elderly patients admitted to intensive care unit after femur fracture surgery: A retrospective observational study. Medicine 99, e22881 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMemtsoudis, S. G. Preoperative Echocardiography in Hip Fracture Patients: A Waste of Time or Good Practice? Anesthesia and analgesia 128, 207\u0026ndash;208 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanty, D. J., Royse, C. F., Kilpatrick, D., Bowyer, A. \u0026amp; Royse, A. G. The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study. Anaesthesia 67, 1202\u0026ndash;1209 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSneyd, J. R., Loxdale, S. J., Werrett, G. \u0026amp; Viira, D. J. Pre-operative echocardiography for hip fracture patients. Anaesthesia 68, 299\u0026ndash;300 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen, X. \u003cem\u003eet al\u003c/em\u003e. Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report. Clinical interventions in aging 15, 755\u0026ndash;762 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLam, C. S. P. \u003cem\u003eet al.\u003c/em\u003e Age-associated increases in pulmonary artery systolic pressure in the general population. Circulation 119, 2663\u0026ndash;2670 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMemtsoudis, S. G., Besculides, M. C., Gaber, L., Liu, S. \u0026amp; Della Gonz\u0026aacute;lez Valle, A. Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. International orthopaedics 33, 1739\u0026ndash;1745 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar, A. \u0026amp; Neema, P. K. Severe pulmonary hypertension and right ventricular failure. Indian journal of anaesthesia 61, 753\u0026ndash;759 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNadruz, W. Myocardial remodeling in hypertension. Journal of human hypertension 29, 1\u0026ndash;6 (2015).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"preoperative echocardiography, cardiac abnormalities, mortality, hip fractures, elderly patients","lastPublishedDoi":"10.21203/rs.3.rs-4806373/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4806373/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eWe sought to identify preoperative cardiac abnormalities associated with postoperative mortality in elderly patients undergoing hip fractures surgery, in order to provide reference for focused transthoracic echocardiography (TTE).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective study, a total of 669 elderly patients (age over 65 years) undergoing hip fractures surgery were included, of which 58(8.7%) died within one-year after discharge. Cox regression analysis models were used to identify the prognostic cardiac abnormalities of postoperative mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eUnivariate analysis showed that age (HR 1.065, 95%CI 1.030\u0026ndash;1.101; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ASA score (III, IV vs. I, II) (HR 1.855, 95%CI 1.098\u0026ndash;3.067; P\u0026thinsp;=\u0026thinsp;0.022), history of chronic obstructive pulmonary disease (COPD)(HR 4.446, 95%CI 1.909\u0026ndash;10.355; P\u0026thinsp;=\u0026thinsp;0.001) and atrial fibrillation (AF)(HR 3.803, 95%CI 1.803\u0026ndash;8.024; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), presence of left ventricular ejection fraction (LVEF)\u0026thinsp;\u0026lt;\u0026thinsp;50%(HR 5.009, 95%CI 2.151\u0026ndash;11.665; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), left ventricular dilatation (HR 3.813, 95%CI 1.730\u0026ndash;8.403; P\u0026thinsp;=\u0026thinsp;0.001), pulmonary arterial systolic pressure (PASP)\u0026thinsp;\u0026gt;\u0026thinsp;25mmHg(HR 4.388, 95%CI 2.492\u0026ndash;7.725; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), moderate-severe aortic valve stenosis (AS) (HR 4.702, 95%CI 1.471\u0026ndash;15.035; P\u0026thinsp;=\u0026thinsp;0.009) were the dominant predictors of mortality within one-year. The presence of LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%, left ventricular dilatation and elevated PASP were proved to be the independent predictors of one-year mortality in elderly patients in multivariate analysis.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCardiac abnormalities derived from preoperative TTE, namely LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%, AS, left ventricular dilatation and elevated PASP had prognostic value for elderly patients undergoing hip fracture surgery. We consider that these indices would be clinically important regarding the preoperative cardiac risk assessment of elderly hip fracture patients who are treated with surgery, which may be assessed in the focused TTE.\u003c/p\u003e","manuscriptTitle":"Preoperative cardiac abnormalities associated with one-year mortality in elderly patients undergoing hip fracture surgery: The role of focused TTE","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-12 12:23:48","doi":"10.21203/rs.3.rs-4806373/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-08-18T01:25:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-09T03:17:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-06T14:16:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-07-26T08:05:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67b31e79-1614-4234-93f8-8ea6d693642f","owner":[],"postedDate":"September 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":36240723,"name":"Health sciences/Health care/Geriatrics"},{"id":36240724,"name":"Health sciences/Health care/Medical imaging/Ultrasonography/Echocardiography"},{"id":36240725,"name":"Health sciences/Health care/Fracture repair"},{"id":36240726,"name":"Health sciences/Medical research/Outcomes research"},{"id":36240727,"name":"Health sciences/Diseases/Cardiovascular diseases"}],"tags":[],"updatedAt":"2024-09-12T12:23:48+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-12 12:23:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4806373","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4806373","identity":"rs-4806373","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}