Anaesthesia 2012, 67, 51–54 doi:10.1111/j.1365-2044.2011.06942.

Original Article
The role of routine pre-operative bedside echocardiography in detecting
aortic stenosis in patients with a hip fracture*
S. J. Loxdale,1 J. R. Sneyd,2 A. Donovan,3 G. Werrett1 and D. J. Viira1

1 Consultant Anaesthetist, Department of Anaesthesia, Derriford Hospital, Plymouth

2 Professor of Anaesthesia, The Peninsula College of Medicine and Dentistry, University of Plymouth, Plymouth
3 Consultant Anaesthetist, Department of Anaesthesia, Taunton and Somerset NHS Foundation Trust, Taunton, UK

Summary
The prevalence and severity of aortic stenosis in unselected patients admitted with a hip fracture is unknown. Derriford Hospital
operates a routine weekday, pre-operative, targeted bedside echocardiography examination on all patients admitted with a hip
fracture. We carried out a prospective service evaluation for 13 months from October 2007 on all 501 admissions, of which 374
(75%) underwent pre-operative echocardiography. Of those patients investigated, 8 (2%) had severe, 24 (6%) moderate and 113
(30%) had mild aortic stenosis or aortic sclerosis. Eighty-seven of 278 (31%) patients with no murmur detected clinically on
admission had aortic stenosis on echocardiography and of the 96 patients in whom a murmur was heard pre-operatively, 30
(31%) had a normal echocardiogram. Detection of a murmur does not necessarily reflect the presence of underling aortic valve
disease. However, if a murmur is heard then the likelihood of the lesion’s being moderate or severe aortic stenosis is increased
(OR 8.5; 95% CI 3.8–19.5). Forty-four (12%) of our unselected patients with fractured femur had either moderate or severe
aortic stenosis (with or without moderate or severe left ventricular failure), or mild stenosis with moderately or severely impaired
left ventricular function.
. .........................................................................................................................................................................
Correspondence to: Dr S. Loxdale
Email: susan.loxdale@nhs.net
*Presented in part at the Annual Congress of the Association of Anaesthetists of Great Britain and Ireland, Harrogate,
September 2010.
Accepted: 12 September 2011

The management of patients admitted with a surgical
diagnosis of hip fracture and an undiagnosed heart murmur
is controversial. In a UK survey, when presented with the
above scenario 20% of respondents would insist on a pre-
operative echocardiogram, 54% would request an echocar-
diogram before surgery only if the patients had suspicious
signs or symptoms, and 26% would go ahead without
investigation [1]. This variation in practice reflects the
dilemma of waiting for echocardiography to provide definite
diagnosis and potentially alter the anaesthetic technique [2],
vs the risk of increased mortality from operative delay [3].
The main anaesthetic concern aroused by an undiagnosed
heart murmur is the possibility of severe aortic stenosis. This
has previously been shown to be a major risk factor for
morbidity [4], and the diagnosis can change anaesthetic
management. McBrien and colleagues reported recently the
echocardiographic findings of patients admitted with frac-
tured hips and new systolic murmurs, and found the incidence
of previously undiagnosed aortic stenosis to be 6.9% [2]. They
suggested that the true incidence in the hip fracture popula-
tion might be greater, as patients with known aortic stenosis
were not included, and there may have been a failure of
murmur identification on auscultation. The true prevalence of
aortic stenosis in this population of patients is unknown.
We audited our practice at Derriford Hospital when
only patients with a clinically detected systolic murmur had
an echocardiogram. These patients waited a mean (SD) of
5.4 (3.4) days after admission for their echocardiogram, and
the mean time to surgery from admission was 7.5 (5.5) days.
In an attempt to reduce the time to surgery, a routine
weekday, pre-operative, bedside, targeted echocardiography
service was developed to examine all patients admitted with

Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 51

Anaesthesia 2012, 67, 51–54
a hip fracture. A service evaluation was conducted to assess
this new intervention. This evaluation aimed to assess the
prevalence and severity of aortic stenosis, the degree of left
ventricular dysfunction, and the frequency with which a
murmur was heard in all patients admitted with a diagnosis
of hip fracture during the study period.
Methods
Local Ethics Committee approval was requested for this
service evaluation but was not required. The Caldicott
Guardian approved the data handling procedures. All
patients who were admitted with the surgical diagnosis of
fractured neck of femur, for 13 months from October 2007,
were included. Data collected from the case notes included
patients’ characteristics (age, sex, ASA physical status),
clinical record of murmurs detected pre-operatively (by
admitting doctor, orthogeriatrician or anaesthetist), previous
diagnosis of valvular heart disease, previous echocardiogram
reports, date and time of admission, and the new echocar-
diogram report.
Senior echocardiography technicians performed echo-
cardiography at the patient’s bedside on the orthopaedic
ward. This was carried out between 08:30 and 09:00 each
morning of the working week (Monday to Friday inclusive).
The written report was placed in the patient’s notes. A Vivid I
Ultrasound machine (GE Healthcare Ltd, Hatfield, UK) was
used. This is a compact, portable, high performance digital
ultrasound device. It provides image acquisition in 2D, M-
mode and Doppler within a range of operating frequencies.
During the targeted echocardiogram, left ventricular func-
tion and aortic valve structure and function were evaluated.
Aortic stenosis was defined as an abnormality of the aortic
valve causing obstruction to the left ventricular outflow.
Aortic stenosis was measured by peak gradient across the
valve and expressed as no stenosis, mild (< 36 mmHg),
moderate (36–64 mmHg) or severe (> 64 mmHg). Patients
with aortic sclerosis were included in the mild aortic stenosis
group. Left ventricular ejection fraction was measured and
expressed as normal (> 50%), mild (40–50%), moderate (30–
40%) and severe (< 30%) impairment.
Following the introduction of the routine echocardiog-
raphy service, the times from admission to echocardiogra-
phy and to surgery were recorded.
The effectiveness of auscultation for detection of aortic
stenosis was explored using logistic regression (using ‘R: A
language and environment for statistical computing’. R
Foundation for Statistical Computing, Vienna, Austria).
Results
In the 13-month study period (from October 2007 to
November 2008), 501 consecutive hip fracture patients were
52
Loxdale et al. | Echocardiography in hip fracture patients
admitted to the hospital. Data were collected on 495 cases;
six case notes were missing. Three hundred and seventy-four
patients underwent pre-operative echocardiography; it was
not obtained in 121. The principal reason for failure to
obtain an echocardiogram was admission to hospital on a
Friday or Saturday and subsequent surgery during the
weekend; in three patients the images obtained were of a
poor quality and they were not included in the further
analysis.
The median (IQR [range]) age of patients was 84 (77–88
[20–102]) years. The majority (94%) of our patients were
> 60 years old. One hundred and fourteen (23%) patients
were male and 381 (77%) female.
The overall prevalence of aortic stenosis was 145 ⁄ 374
(39%). Severe or moderate aortic stenosis was detected in 8%
and severe or moderate left ventricular impairment was
detected in 7% of patients (Table 1). Of the 24 patients with
moderate aortic stenosis, five had moderately or severely
impaired left ventricular function (Table 2). None of the
patients with severe stenosis had moderate or severely
impaired function. A murmur was detected in 113 (22%) of
the 495 admitted patients and in 96 (26%) of the 374
patients who underwent echocardiography. Of the eight
patients with severe aortic stenosis, a murmur was noted in
seven (Table 3), and of the 24 patients with moderate
stenosis, a murmur was noted in 16. Overall, 87 (31%)
patients with no murmur heard during clinical examination
had aortic stenosis or sclerosis on echocardiography, of
which nine were moderate or severe. Auscultation of a
murmur was associated with a greater risk of moderate or
severe aortic stenosis (OR 8.5; 95% CI 3.8–19.5).
Following the introduction of the routine echocardiog-
raphy service the mean (SD) time to echocardiography was
1.0 (0.7) days and the time to surgery was 2.9 (1.9) days.
Table 1. Prevalence and severity of aortic stenosis and left
ventricular function as determined by echocardiography in
hip fracture patients. Values are number (proportion).
n = 374
Valve abnormality
No abnormality detected 205 (55%)
Mild stenosis or sclerosis 113 (30%)
Moderate stenosis 24 (6%)
Severe stenosis 8 (2%)
Other valve lesions 24 (6%)
Left ventricular function
Good 201 (54%)
Mild impairment 147 (39%)
Moderate impairment 23 (6%)
Severe impairment 3 (1%)
Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland
Loxdale et al. | Echocardiography in hip fracture patients Anaesthesia 2012, 67, 51–54

Table 2. Relationship between the severity of aortic stenosis 65 years in the general population, with an incidence in the
and left ventricular (LV) function in hip fracture patients. over 75s of 2.8% [6]. McBrien and his team studied a large
Values are number (proportion). population of patients who were admitted with a fractured
Degree of aortic neck of femur. Echocardiograms were performed in 1167
stenosis LV function Number of 3997 cases, the majority for assessment of an undiagnosed
None (n = 205) Good 123 (60%) murmur. The incidence in this selected group was 6.9% [2].
Mild impairment 74 (36%) Our findings are therefore comparable with previous studies.
Moderate 8 (4%)
Importantly, our patients were unselected.
impairment
Severe 0 Patients with severe aortic stenosis and a low cardiac
impairment output often present with a low transvalvular pressure
Mild stenosis Good 43 (38%)
or sclerosis Mild impairment 58 (51%) gradient [7]. This is a function of underestimation of aortic
(n = 113) Moderate 11 (10%) jet velocity on echocardiogram (the impaired ventricle fails
impairment
to generate enough pressure to create the ‘real’ gradient
Severe impairment 1 (1%)
Moderate Good 8 (33%) between the left ventricle and the aorta). Such patients can
stenosis Mild impairment 11 (46%) be difficult to distinguish from those with low cardiac output
(n = 24) Moderate 3 (12%)
impairment and only mild to moderate aortic stenosis. Low-dose
Severe impairment 2 (8%) dobutamine stress echocardiography can be used to deter-
Severe stenosis Good 6 (75%)
mine whether the actual stenosis is severe or moderate [8],
(n = 8) Mild impairment 2 (25%)
Moderate impairment 0 but this may lead to greater delays and its associated risks.
Severe impairment 0 By estimating both aortic stenosis and left ventricular
Other valve Good 21 (87%)
lesion Mild impairment 2 (8%) function we hoped to avoid underestimating the severity of
(n = 24) Moderate 1 (4%) disease in patients with apparently mild stenosis. While our
impairment
study identified five patients with moderate or severe left
Severe impairment 0
ventricular impairment amongst those with moderate or
severe aortic stenosis, we found a further 12 patients with
Discussion such a degree of impaired left ventricular function in
Aortic stenosis is increasingly common in our ageing patients whose stenosis was mild. Therefore, 44 ⁄ 374 (12%)
population and its severity increases with age. Before our of unselected patients with fractured femur had either
report, the prevalence and severity of aortic stenosis in an moderate or severe aortic stenosis (with or without mod-
unselected patient population admitted with a surgical erate or severe left ventricular failure), or mild stenosis with
diagnosis of hip fracture was unknown. We found that 8% of moderately or severely impaired left ventricular function.
patients who underwent echocardiography had either mod- Classically, a loud (grade 4 ⁄ 6), late-peaking systolic
erate or severe stenosis. Since we investigated all patients murmur radiating to the carotid arteries, a single or
present when the echocardiography technician was avail- paradoxically split second heart sound, and a delayed and
able, our data should reflect the entire population of diminished carotid upstroke, confirm the presence of severe
fractured femur patients. aortic stenosis. However, physical examination findings are
A population-based sample from Finland of 501 people specific but not sensitive for making the diagnosis and
reported echocardiographic findings of moderate to severe determining its severity [9]. In previous work, it is usually only
aortic valve stenosis in 8.8% of females and 3.6% of males in those patients who had a previously undiagnosed systolic
patients aged 75–86 years [5]. Data from the USA showed murmur that would have undergone pre-operative echocar-
an increasing incidence of aortic stenosis after the age of diography [2]. Our evaluation revealed that 87 ⁄ 278 (31%) of

Table 3. Presence of a murmur detected by auscultation in relationship to severity of aortic stenosis by echocardiography in hip
fracture patients. Values are number (proportion).

Mild stenosis Moderate Severe

No abnormality or sclerosis stenosis stenosis Other lesion
Murmur heard 30 (31%) 35 (36%) 16 (17%) 7 (7%) 8 (8%)
(n = 96)
No murmur heard 175 (63%) 78 (28%) 8 (3%) 1 (0.5%) 16 (6%)
(n = 278%)

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Anaesthesia 2012, 67, 51–54
patients without clinically detected murmurs had aortic
stenosis. Conversely, in the 96 patients where a murmur
was heard, 30 (31%) had a normal echocardiogram. Thus,
pre-operative auscultation of a murmur does not necessarily
reflect either the presence or the severity of the under-
lying aortic valve disease. However, if a murmur is heard,
then moderate or severe aortic stenosis is 8.5 times more
likely.
A busy ward is not the best place for a full cardiological
examination, and the grade and experience of the examining
doctor varies considerably. However, our data represent the
‘real world’ and reflect the realities of a busy surgical service.
After establishing our routine echocardiology service,
time to surgery dramatically reduced. Although part of this
improvement was a function of reduced anaesthetic delay as
a result of the echocardiography, other factors also contrib-
uted. We did not evaluate whether the echocardiography
result led to a change in anaesthetic practice, but the
presence of aortic stenosis or left ventricular dysfunction
did alter pre-operative consultations and the process for
obtaining informed consent, as well as targeting invasive
monitoring and increasing clinicians’ vigilance.
In conclusion, we have demonstrated a point prevalence
of aortic stenosis of 39% in our hip fracture population, of
whom 8% had moderate or severe stenosis.
Acknowledgements
The authors wish to thank Linda Zacharkiw, Senior
Echocardiology technician, and her team for performing
54
Loxdale et al. | Echocardiography in hip fracture patients
these echocardiograms. No external funding and no com-
peting interests declared.
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Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland