Background
	Osteoporotic hip fractures typically occur in frail, elderly patients with multiple medical comorbidities. The pre-operative evaluation process sometimes involves transthoracic echocardiography (TTE) to screen for significant heart disease that would alter peri-operative management. Evidence suggests that use of guidelines and care pathways can improve the effectiveness of care delivered, but it is unclear which guidelines/pathways are the most useful in patients with hip fractures.

Methods
	We performed a retrospective chart review based on a prospective registry of osteoporotic hip fracture patients to identify all patients who underwent pre-operative TTE. The history, physical exam findings, and listed indications for TTE were compared to those given in five commonly utilized clinical practice guidelines (CPGs): American College of Cardiology (ACC/AHH), British Society of Echocardiography (BSE), European Society of Echocardiography (ESC/ESE), Association of Anesthesia of Great Britain and Ireland (AAGBI), and Scottish Intercollegiate Guidelines Network (SIGN). The performance of these guidelines (sensitivity, specificity) for identifying which patients would have TTEs with information with potential to change peri-operative management was calculated.

Results
	One hundred patients were identified receiving pre-operative TTE, and the patients met criteria for TTE 32-66% of the time, based on the individual CPG used. TTE revealed new information with the potential to change management 14% of the time. As a screening tool, the ACC/AHH and SIGN guidelines performed the best, both with 100% sensitivity for identifying which patients may benefit from TTE.

Conclusions
	Prior to fixation of osteoporotic hip fractures, TTE can be a useful tool for identifying pathology that may directly lead to changes in peri-operative in medical or anesthesia management. Based on this data, established CPGs can be safely used to identify which patients should receive pre-operative TTE with low risk or missed pathology. The guidelines that were the most sensitive tended to focus on a change in clinical status in patients with known disease, or clinical concern for new onset disease of at least moderate severity.

Variable Performance of Evidence-Based Guidelines for Echocardiography in Patients With Hip Fractures