Atrial fibrillation (AF) does increase mortality risk after fractures, particularly in elderly patients with fragility fractures such as hip fractures. This relationship is complex and involves several interrelated factors including the patient’s cardiovascular health, the stress of surgery, and the body’s response to trauma.
Fragility fractures, especially proximal femoral (hip) fractures, are common in older adults and carry a high risk of death within the first year after injury. Mortality rates within 30 days of such fractures range from about 6% to 10%, and can exceed 25% at one year. Atrial fibrillation, especially when it occurs postoperatively (postoperative atrial fibrillation or POAF), is one of the most frequent cardiac complications in these patients and is strongly linked to increased morbidity and mortality.
The reasons AF increases mortality after fractures include:
– **Cardiovascular strain and instability:** AF causes irregular and often rapid heartbeats, which can reduce the efficiency of the heart’s pumping action. This can worsen pre-existing heart conditions such as ischemic heart disease and heart failure, both of which are common in elderly fracture patients. The irregular rhythm can lead to poor blood flow and increase the risk of stroke or heart failure exacerbation.
– **Increased risk of thromboembolism:** AF promotes blood clot formation in the atria, which can travel to the brain or other organs causing strokes or embolic events. After a fracture and surgery, patients are already at increased risk for blood clots due to immobility and inflammation, compounding the danger.
– **Surgical and perioperative stress:** Surgery for fractures, especially hip fractures, triggers a systemic inflammatory response and physiological stress that can precipitate or worsen AF. The perioperative period is critical because AF onset here is associated with worse outcomes, including higher mortality.
– **Comorbidities and frailty:** Patients with AF often have multiple other health issues such as hypertension, diabetes, chronic kidney disease, and pulmonary problems. These comorbidities increase vulnerability to complications after fractures and surgery.
– **Impact on rehabilitation and recovery:** AF and its complications can delay mobilization and rehabilitation after fracture repair, which are crucial for recovery. Prolonged immobility increases risks of pneumonia, deep vein thrombosis, and muscle wasting, all contributing to higher mortality.
– **Medication challenges:** Managing AF often requires anticoagulation to prevent stroke, but anticoagulants increase bleeding risk, which complicates surgical management and postoperative care in fracture patients.
Studies have shown that postoperative AF is the most common arrhythmia after hip fracture surgery and is linked to significantly higher rates of death and complications. The presence of AF before or after fracture surgery is a marker of poor prognosis. This is partly because AF reflects underlying cardiac dysfunction and partly because it directly contributes to adverse events.
In addition, the interplay between AF and heart failure is important. Heart failure is common in elderly fracture patients and worsens outcomes. AF can exacerbate heart failure by impairing cardiac output, and heart failure can promote AF through atrial stretch and neurohormonal activation. This vicious cycle further increases mortality risk.
Management strategies to reduce mortality in fracture patients with AF focus on:
– **Optimizing cardiac status before surgery:** Careful cardiovascular evaluation and stabilization can reduce perioperative complications.
– **Monitoring and early detection of AF:** Prompt identification of new or worsening AF allows timely treatment.
– **Appropriate anticoagulation balancing bleeding and clotting risks:** This is challenging but critical to prevent strokes without causing excessive bleeding.
– **Multidisciplinary care:** Coordination between orthopedic surgeons, cardiologists, anesthesiologists, and rehabilitation teams improves outcomes.
– **Addressing modifiable risk factors:** Controlling hypertension, managing heart failure, and treating sleep apnea or other conditions that predispose to AF can help.
In summary, atrial fib