5% and 17.7%, respectively.   Step 2 Does a patient have a Nutlin-3 concentration functional capacity greater than or equal to 4 METSs without symptoms? (modified from [11]) Table 2 summarizes the estimated energy requirement for various common daily activities. It has been extensively confirmed that a patient’s functional status reliably predicts perioperative and long-term cardiac events [23–26]. For asymptomatic patients with a functional capacity of 4 METs or above, the need for any active preoperative cardiac intervention to lower the perioperative risk is unlikely [11].   Step 3 If the patient has

poor functional Seliciclib mw capacity, is symptomatic, or has unknown function, then the presence of clinical risk factors including [1] coronary artery disease [2], compensated heart failure [3], previous cerebrovascular accident [4], diabetes mellitus, and [5] renal insufficiency, Apoptosis antagonist will determine the need for further evaluation (modified

from [11]). As hip repair surgery is considered intermediate-risk surgery, even in the presence of risk factors, further cardiac investigations are not generally considered necessary. While fulfilling these three steps mentioned above provides cardiac clearance for surgery, underlying medical conditions may still warrant medical attention and cardiac consultation, for example, patients with medical assistance devices (permanent pacemaker and automatic implantable cardioverter defibrillator), and those prescribed dual antiplatelet agents or oral anticoagulants.   Clinical pathway for hip fracture management While the above-described guidelines provide an invaluable tool for the attending cardiologist to determine perioperative risk for a patient with hip fracture, it does not alert the primary clinician, often an orthopedic surgeon, as to when a cardiac consultation should be initiated. Surgery may be delayed because cardiac clearance cannot be promptly obtained. In order to “fast-track” hip fracture patients for a timely surgery (within Immune system the first 24 h), a clinical pathway for hip fracture

management has been implemented at our hospital since 2008. The frontline orthopedic surgeon and/or intern evaluates the patient’s cardiovascular status according to a checklist (Appendix 1) and determines whether a cardiac consultation is required, even prior to the anesthetist’s assessment. As a result, cardiac clearance is usually obtained within the same day. When further investigations, such as echocardiography, are required, they can be scheduled for the following morning. Surgery can still be performed within 24 h of admission. Summary Hip fracture represents one of the major medical problems faced by our aging society. Early surgery may reduce in-hospital, short-term, and long-term morbidity and mortality. Careful screening of patients with hip fracture to enable prompt cardiac assessment can improve overall outcome by minimizing unnecessary delays for cardiac clearance.