Authors: Khan, James S. et al.
Anesthesiology October 2025 | DOI: 10.1097/ALN.0000000000005818
This secondary analysis of the international HIP ATTACK randomized controlled trial examined whether perioperative pain contributes to myocardial injury in patients undergoing surgery for hip fracture. Because hip fracture patients often experience severe pain and physiological stress, the authors explored whether higher pain levels are independently associated with troponin elevation and ischemic cardiac events.
The study included 2,430 participants (82% of the parent cohort) who had both troponin and pain score data. Pain was rated daily using a 0–10 Numeric Rating Scale and categorized as mild (0–3), moderate (4–7), or severe (8–10). Troponin elevation from any cause was the primary endpoint, while secondary outcomes included myocardial injury, myocardial infarction (MI), and a composite of both.
Nearly half of the cohort (45%) experienced troponin elevation. In adjusted models, both moderate (OR 3.90, 95% CI 3.02–5.05) and severe pain (OR 29.24, 95% CI 17.7–48.27) were strongly associated with elevated troponin. Moderate (OR 2.09, 95% CI 1.71–2.57) and severe pain (OR 6.04, 95% CI 4.49–8.12) were linked to myocardial injury, while only severe pain predicted myocardial infarction (OR 2.33, 95% CI 1.35–3.99). Both pain categories correlated with the combined outcome of myocardial injury or infarction.
The findings suggest that unrelieved pain acts as a physiological stressor capable of precipitating myocardial ischemia in frail surgical patients. This underscores the potential cardiovascular consequences of inadequate analgesia, especially in the perioperative management of hip fracture.
What You Should Know
In hip fracture surgery, moderate to severe perioperative pain substantially increases the risk of myocardial injury and infarction. Effective analgesic strategies may help mitigate cardiac complications by reducing sympathetic activation and stress-related ischemia.
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