Authors: Khan JS et al.
Journal: Anesthesiology, December 4, 2025. DOI: 10.1097/ALN.0000000000005818
Summary
This prespecified secondary analysis of the HIP ATTACK randomized trial examined whether perioperative pain severity is associated with myocardial injury and ischemic events in patients undergoing hip fracture surgery. Hip fracture patients are particularly vulnerable to cardiovascular complications, and uncontrolled pain may provoke sympathetic activation, tachycardia, hypertension, and myocardial oxygen supply–demand imbalance.
The analysis included 2,430 patients from the original HIP ATTACK cohort who had both troponin measurements and recorded pain scores. Pain intensity was assessed daily using a numeric rating scale and categorized as mild, moderate, or severe. Average pain scores prior to and on the day of the first troponin elevation were used for analysis. Outcomes included troponin elevation from any cause, ischemic myocardial injury, myocardial infarction, and a composite ischemic endpoint, with adjustment for relevant clinical confounders.
Nearly half of the cohort experienced a troponin elevation. Moderate and severe pain demonstrated strong, graded associations with troponin elevation and myocardial injury. Severe pain showed a particularly striking association, conferring markedly higher odds of troponin elevation and significantly increased risk of myocardial infarction. Both moderate and severe pain were associated with the composite ischemic outcome, indicating a dose–response relationship between pain intensity and myocardial risk.
These findings suggest that pain is not merely a symptom but may function as a physiologic stressor contributing to myocardial injury in this high-risk population. The study highlights perioperative pain control as a potentially modifiable factor in reducing cardiovascular complications after hip fracture surgery.
Key Points
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Nearly half of hip fracture patients experienced perioperative troponin elevation.
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Moderate and severe pain were independently associated with troponin elevation and myocardial injury.
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Severe pain was associated with myocardial infarction.
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A clear dose–response relationship existed between pain severity and ischemic outcomes.
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Pain may act as a physiologic driver of myocardial stress and injury.
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Findings support aggressive, timely pain management as a potential strategy to reduce perioperative cardiac risk.
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