Cardiac murmurs are often present in older people; insignificant aortic sclerosis or mild mitral regurgitation are the most common. A large retrospective study showed that 6.9 % of patients with hip fracture had previously undiagnosed significant aortic stenosis [17]. This may influence the type of anaesthetic and the need for invasive cardiac monitoring. Significant aortic stenosis is suspected if the patient has an ejection systolic murmur in the aortic area in combination with a history of angina on exertion, unexplained syncope or near syncope, a slow rising pulse clinically in the brachial artery, an absent 2nd heart sound or LVH on the ECG without hypertension. Patients with significant aortic stenosis require careful fluid balance and are at high risk of pulmonary oedema.

Many older patients will have a history or symptoms in keeping with poor ventricular function on a background of hypertension, ischaemic heart disease, valvular heart disease or atrial fibrillation. The mainstays of medical treatment are diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers, aldosterone antagonists and a combination of hydralazine and nitrates. Increasingly, therapies for heart failure include electrophysiological interventions such as cardiac resynchronization therapy (CRT), pacemakers with or without implantable cardioverter-defibrillators (ICDs). Severity can usually be gauged from the history, symptoms and required medication.

Those who are euvolaemic should undergo early surgery omitting heart failure medication until 48–72 h post-operatively. Caution should be observed with administering intravenous fluid. Anaemia should be managed proactively to maintain haemoglobin levels above 100 g/l. Once able to transfer out of bed medication can be slowly re-introduced. These patients often develop increasing peripheral oedema 5–7 days post operatively and may require an increased dose of diuretics for a period of time.

Patients with decompensated heart failure and fluid overload at presentation need careful attention. Those with acute left ventricular failure need stabilising before theatre. This is often associated with an acute ischaemic event. Antiplatelet and anticoagulant therapy may cause increased blood loss at the fracture site and should only be started with caution for acute cardiac ischaemia. Discussion with cardiologists regarding appropriate intervention and an individualised decision about timing of surgery should be made.

Those with poor right ventricular function and fluid overload need high dose diuretics with close monitoring of peripheral oedema levels, weight and renal function. This is often associated with hyponatraemia, hypotension and renal impairment and requires close observation. Correction to achieve a euvolaemic state often takes 5–10 days. It is usually better to proceed with surgery and manage the decompensated heart failure in the post-operative period. Significant peripheral oedema in the thigh however may increase the risk of wound breakdown.

Pacemakers have become increasingly sophisticated and a basic knowledge of different devices and their indications is required to aid the acute management of patients with fragility fracture. All patients with pacemakers have routine annual checks and a pre-operative check is only required if there is concern about malfunction or if it has not been checked within the previous 12 months.

It is important to understand the reason for the device and whether the patient is pacemaker-dependent. External pacing equipment and a defibrillator must be available during surgery.

The use of surgical diathermy/electrocautery can give rise to electrical interference and this can present additional risks when used in patients with pacemakers and ICDs. Energy can also be induced into heart lead systems causing tissue heating at lead tips through high frequency current [18]. The manufacturers recommend avoiding surgical diathermy if surgery is occurring within 50 cm from the device. If diathermy is deemed essential then the use of Bipolar diathermy with short bursts of energy minimises the risk. Where available, the use of a harmonic scalpel should be considered.

If a cardiac technician is available then an ICD device can be turned onto monitor only mode to prevent shock delivery during surgery. Otherwise, ICDs should be turned off by placing a magnet over the device, and securing it with micropore tape. Any sustained VT or VF intraoperatively should be managed with external defibrillation. Post-operatively the magnet should be removed and the patient monitored until the device has been checked.

Public campaigns such as ‘know your pulse’ have increased public awareness of the risk of stroke from atrial fibrillation. Patients with AF and a controlled ventricular rate should continue with rate control medication (usually a beta-blocker, dioxin or verapamil) pre-operatively with their usual dose administered on the day of surgery. A history of atrial fibrillation may be permanent (AF) or paroxysmal (PAF). Amiodarone, Flecanide or beta-blockers are often used to maintain sinus rhythm and prevent PAF. Peri-operative AF is common in these patients.

Those with new AF, persistent AF or PAF with a fast ventricular rate need review. Tachycardia may be due to pain, a cardiac event or sepsis and clinical review with a 12 lead ECG, measurement of lactate and inflammatory markers is advised. Those with no evidence of inter-current illness may simply have new AF or poor rate control. If the rate is persistently above 110 bpm then urgent rate control is required pre-operatively. Digoxin and beta-blockers (iv metoprolol) may take 24 h to establish rate control. The most effective method is with intravenous Amiodarone. This is usually administered with a slow bolus of 300 mg over 1 h followed by a 24-h infusion of 0.5 mg/kg/h (450 mg in 500 ml Normal Saline). This must be administered through a large bore cannula and ideally into a central line with cardiac monitoring. Cardiology advice may be required for complex patients.