New murmur and breathlessness before hip replacement — case discussion

Presentation

Practice case (not a real patient). A 76-year-old woman is referred from the orthopaedic clinic before an elective total hip replacement for osteoarthritis. Over 6 months she has become breathless walking up one flight of stairs, and her ankles swell by evening. She has hypertension treated with perindopril and indapamide, and type 2 diabetes treated with metformin and dapagliflozin. A systolic murmur is heard that has not been noted before.^[1]

Step 1 — Surgical and patient risk

Total hip replacement sits in the intermediate surgical risk band of ESC 2022 Table 5 (neurological or orthopaedic: major, hip and spine surgery), an estimated 30 day risk of CV death, MI and stroke of 1–5%.^[1] She is over 65 with CV risk factors, which ESC 2022 says raises the risk of undetected CVD and of peri-operative complications.^[1] She also has new symptoms and signs that may be cardiac, though ESC 2022 notes that dyspnoea and oedema may also have non-cardiac causes.^[1]

Step 2 — First tests

With dyspnoea and peripheral oedema, ESC 2022 says an ECG and an NT-proBNP/BNP test are indicated before NCS, unless there is a certain non-cardiac explanation (Class I, Level C).^[1] With a newly detected murmur and symptoms or signs of CVD, TTE is recommended before NCS (ESC 2022, Class I, Level C).^[1] As she has CV risk factors including age ≥65 years and symptoms suggestive of CVD, hs-cTn T or I is recommended before intermediate- and high-risk NCS and at 24 h and 48 h afterwards (ESC 2022, Class I, Level B).^[1]

Her NT-proBNP is 1450 pg/mL, above the ESC 2022 abnormal threshold of ≥125 pg/mL.^[1] With dyspnoea and/or peripheral oedema and elevated NT-proBNP/BNP, TTE is recommended before NCS (ESC 2022, Class I, Level C).^[1]

Step 3 — The echocardiogram

TTE shows severe aortic stenosis with normal LV systolic function. She is symptomatic, so ESC 2022 recommends AVR (SAVR or TAVI) before elective intermediate- or high-risk NCS (Class I, Level C).^[1] The ESC/EACTS 2025 key message on symptomatic severe AS says that in patients planned for elective NCS, AV intervention is recommended prior to NCS (no class or level given).^[2] Her hip surgery can be deferred, so in her severe symptomatic AS, ESC/EACTS 2025 says a pre-operative Heart Team should decide whether SAVR or TAVI is preferable.^[2]

ESC 2022 notes that severe symptomatic AS is a significant risk factor for post-operative MI and HF, and a predictor of 30 day and long-term mortality after NCS.^[1] The ESC 2022 row on balloon aortic valvuloplasty as a bridge (may be considered; Class IIb, Level C) is for severe symptomatic AS in need of time-sensitive NCS or when TAVI and SAVR are unfeasible, neither of which applies to her.^[1]

Step 4 — Her drugs when the hip surgery goes ahead

After her valve is treated, her breathlessness and ankle swelling resolve, she has no heart failure, and the hip replacement is rebooked. Because she now has no heart failure, withholding perindopril on the day of surgery should be considered to prevent peri-operative hypotension (ESC 2022, Class IIa, Level B).^[1] Indapamide is a diuretic for hypertension, so transient discontinuation on the day of surgery should be considered (ESC 2022, Class IIa, Level B).^[1] Interrupting dapagliflozin for at least 3 days before intermediate- and high-risk NCS should be considered (ESC 2022, Class IIa, Level C).^[1] She should get individualized instructions on these changes, in verbal and written formats (ESC 2022, Class I, Level C).^[1]

Step 5 — After surgery

Her pre-operative hs-cTn T gives the baseline.^[1] ESC 2022 defines PMI as an absolute rise of more than the ULN on day 1 or 2 against that value.^[1] High awareness of peri-operative CV complications combined with PMI surveillance is recommended in intermediate- or high-risk NCS (ESC 2022, Class I, Level B).^[1] ESC 2022 says PMI is largely asymptomatic in about 90% of patients, so surveillance, not symptoms, finds it.^[1]

Teaching points

• Dyspnoea or oedema before NCS: ECG and NT-proBNP/BNP are indicated unless there is a certain non-cardiac explanation, and with elevated NT-proBNP/BNP, TTE is recommended (ESC 2022, each Class I, Level C).^[1]
• Symptomatic severe AS before elective intermediate- or high-risk NCS: AVR (SAVR or TAVI) first (ESC 2022, Class I, Level C).^[1]
• Drug rows that apply to her: in patients without HF, withholding the RAAS inhibitor on the day of NCS should be considered to prevent peri-operative hypotension (ESC 2022, Class IIa, Level B); for patients on diuretics to treat hypertension, transient discontinuation of the diuretic on the day of NCS should be considered (ESC 2022, Class IIa, Level B); interrupting SGLT-2 inhibitor therapy for at least 3 days before intermediate- and high-risk NCS should be considered (ESC 2022, Class IIa, Level C).^[1]
• PMI: an absolute hs-cTn rise of more than the ULN on day 1 or 2 against the pre-operative value (ESC 2022).^[1]