skip to main content

Postoperative anaemia with acute coronary syndrome after hip fracture surgery — SCE Geriatric Medicine MCQ

Instant feedback + full explanation. One question, done properly.

HardOrthogeriatricsPostoperative anaemia with acute coronary syndrome after hip fracture surgerySCE Geriatric Medicine

An 86-year-old woman is reviewed on the first day after cephalomedullary nailing of an intertrochanteric femoral fracture. She has stable coronary artery disease and heart failure with preserved ejection fraction. Her preoperative haemoglobin was 112 g/L and is now 76 g/L. There is no wound bleeding, thigh swelling or haemodynamic instability. During physiotherapy she develops central chest pressure. ECG shows new horizontal ST-segment depression in leads V4–V6, and high-sensitivity troponin rises from 24 ng/L to 186 ng/L over 3 hours. Her chest pain settles with initial anti-ischaemic treatment, and acute non-ST-elevation myocardial infarction is diagnosed. She is not clinically congested. Which is the most appropriate red-cell transfusion strategy?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Transfuse one unit of red cells, then reassess clinically and recheck the haemoglobin, targeting 80–100 g/L

Explanation lettering: D = shown as A · C = shown as B · B = shown as C · A = shown as D

This patient has postoperative anaemia complicated by objectively confirmed acute coronary syndrome: ischaemic chest pain, dynamic ST-segment depression and a substantial troponin rise. This is an exception to the usual restrictive threshold of 70 g/L. NICE advises considering transfusion at 80 g/L in acute coronary syndrome, with a post-transfusion target of 80–100 g/L. Because she is haemodynamically stable and has no active bleeding, red cells should be given one unit at a time, followed by clinical reassessment and repeat haemoglobin measurement. Her heart failure also increases the importance of avoiding unnecessary multi-unit transfusion and circulatory overload. A applies to most stable adults without acute coronary syndrome, but not to this patient. B reaches the appropriate haemoglobin range but gives two units without interval reassessment. C cannot correct myocardial oxygen-delivery compromise promptly and uses the wrong threshold. E reflects an unjustified liberal strategy: routinely exceeding 100 g/L has not improved mortality or walking recovery after hip-fracture surgery in patients with cardiovascular disease or risk factors. Further red cells would be appropriate only if reassessment after the first unit showed persistent ischaemia or failure to reach the acute coronary syndrome target.

Reference: NICE NG24: Blood transfusion — Red blood cell transfusion (2015) — https://www.nice.org.uk/guidance/ng24/chapter/Red-blood-cell-transfusion Liberal or restrictive transfusion in high-risk patients after hip surgery (2011) — https://pubmed.ncbi.nlm.nih.gov/22168590/