Bhanu P. Gupta

BACKGROUND: Patterns of clinical symptoms and outcomes of perioperative myocardial infarction (PMI) in elderly patients after hip fracture repair surgery are not well defined.METHODS: A retrospective 1:2 case‐control study in a cohort of 1212 elderly patients undergoing hip fracture surgery from 1988 to 2002 in Olmsted County, Minnesota.RESULTS: The mean age was 85.3 ± 7.4 years; 76% female. PMI occurred in 167 (13.8%) patients within 7 days, of which 153 (92%) occurred in first 48 hours; 75% of patients were asymptomatic. Among patients with PMI, in‐hospital mortality was 14.4%, 30‐day mortality was 29 (17.4%), and 1‐year mortality was 66 (39.5%). PMI was associated with a higher inpatient mortality rate (odds ratio [OR], 15.1; confidence interval [CI], 4.6–48.8), 30‐day mortality (hazard ratio [HR], 4.3; CI, 2.1–8.9), and 1‐year mortality (HR, 1.9; CI, 1.4–2.7).CONCLUSION: Elderly patients, after hip fracture surgery, have a higher incidence of PMI and mortality than what guidelines indicate. The majority of elderly patients with PMI did not experience ischemic symptoms and required cardiac biomarkers for diagnosis. The results of our study support the measurement of troponin in postoperative elderly patients for the diagnosis of PMI, in order to implement in‐hospital preventive strategies to reduce PMI‐associated mortality. Journal of Hospital Medicine 2012. © 2012 Society of Hospital Medicine

In reply We appreciate the excellent suggestion by Esposito and Giugliano, which is to conduct a responders' analysis (ie, to evaluate the response [International Index of Erectile Function {IIEF-5} score ≥22] to lifestyle interventions as a dichotomous outcome). If we consider an IIEF-5 score of 22 or higher to be consistent with the achievement of normal sexual function after lifestyle intervention and cardiovascular risk factors reduction, we would have data available from 3 studies.^1-3 A fixed-effect meta-analysis of these 3 studies revealed that lifestyle interventions reduce the odds of erectile dysfunction (ED) (odds ratio, 0.48; 95% CI, 0.26-0.89). This effect lost statistical significance under a random effects model but remained as a strong trend. The heterogeneity of this meta-analysis was likely due to differences in study populations. In contrast to the relatively younger and nondiabetic populations in the studies by Esposito et al,^1,2 the study population of Wing et al³ consisted of diabetic men with average age of 60 years, explaining the irreversibility of ED.

Review from JAMA Internal Medicine — The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on Erectile Dysfunction — A Systematic Review and Meta-analysis