An 86-year-old woman with concurrent STEMI and unstable pertrochanteric fracture was managed conservatively due to high surgical risk but died 52 days post-admission.
How should geriatric patients with simultaneous STEMI requiring DAPT and pertrochanteric fracture requiring urgent surgery be managed?
86-year-old woman with an unstable pertrochanteric fracture of the right femur (AO/OTA 31-A2), anterior STEMI, new-onset atrial fibrillation, and severely reduced LVEF (10%).
Urgent coronary angiography with rotational atherectomy, intravascular lithotripsy, and stent implantation for a critical mid-LAD lesion, followed by DAPT (aspirin + clopidogrel), LMWH, and conservative management with skeletal traction (6 kg) for the fracture.
Clinical course and mortalityhard clinical
Managing simultaneous STEMI and pertrochanteric fracture in geriatric patients is highly complex due to competing risks of bleeding and thrombosis, highlighting the need for multidisciplinary decision-making and specific guidelines.
Absolute Event Rate: 0% vs 0%
Background: Managing elderly patients with simultaneous acute cardiovascular and orthopedic emergencies presents a unique challenge. While ST-elevation myocardial infarction (STEMI) requires prompt revascularization and dual antiplatelet therapy (DAPT), pertrochanteric femoral fractures usually necessitate early surgical fixation to reduce morbidity and mortality. However, the combination of these conditions complicates both standard treatment pathways. Case presentation: We present the case of an 86-year-old woman admitted after a low-energy fall, with a radiologically confirmed unstable pertrochanteric fracture of the right femur (AO/OTA 31-A2). Upon routine electrocardiogram, anterior STEMI with new-onset atrial fibrillation was diagnosed. Although asymptomatic from a cardiac perspective, bedside echocardiography revealed a severely reduced left ventricular ejection fraction of 10%. Urgent coronary angiography demonstrated a critical mid-left anterior descending lesion, successfully treated with rotational atherectomy, intravascular lithotripsy, and stent implantation. She was initiated on DAPT (aspirin + clopidogrel) and anticoagulated with low-molecular-weight heparin. Given the extremely high bleeding risk, surgical intervention for the femoral fracture was deemed unsafe. Instead, conservative management with skeletal traction (6 kg) was employed. Despite optimal supportive care and early rehabilitation, the patient experienced a complicated hospital course, including delirium, hematuria, and lower respiratory tract infection. She passed away 52 days post-admission. Conclusions: This case illustrates the complexity of clinical decision-making in geriatric patients with competing acute conditions. Current evidence on how to proceed in patients requiring both antithrombotic therapy and urgent orthopedic surgery is limited. Multidisciplinary teams must carefully weigh the risks and benefits of both surgical and conservative strategies. Further guidelines addressing such scenarios in elderly patients are urgently needed.
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Jozef Dodulík
University of Ostrava
Jiří Demel
University of Ostrava
Jan Mrózek
University of Ostrava
Journal of Cardiovascular Development and Disease
University of Ostrava
University Hospital Ostrava
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Dodulík et al. (Wed,) reported a other. An 86-year-old woman with concurrent STEMI and unstable pertrochanteric fracture was managed conservatively due to high surgical risk but died 52 days post-admission.
synapsesocial.com/papers/69b3acb202a1e69014ccea81 — DOI: https://doi.org/10.3390/jcdd13030132