Aortic stenosis is the most common form of acquired valvular heart disease in developed countries; it is estimated to occur in 2-4% of the population aged over 65 years old . It is not uncommon to have a hip fracture patient with a cardiac murmur, or even aortic stenosis. It appears that the combination may be associated with a higher morbidity and mortality rate.
Pre-operative cardiac testing has its place in the elective setting. In the emergent situation, the clinician needs to evaluate the risk incurred by waiting for the cardiac testing when compared to the risks associated with the delay to surgery. In a recent national survey of anaesthetists on the perioperative management of hip fracture patients with a previously undiagnosed heart murmur, the responses were mixed. Most anaesthetists would ask for a pre-operative echocardiogram in the presence of suspicious signs or symptoms, whereas 19.8% would be prompted to use invasive monitoring without an echocardiogram .
According to Parker et al, regional and general anaesthesia produce comparable results for hip surgery outcome . Pellikka et al  reported that surgery may not pose any additional risks for patients with aortic stenosis. There was no report of statistically significant difference in anaesthetic management of hip fracture patients with different severity of aortic stenosis compared to patients without aortic stenosis by Adunsky et al . McBrien et al  reported a trend towards general anaesthesia versus spinal anaesthesia in hip fracture patients with varying severity of aortic stenosis; invasive monitoring was also used in some patients. Whilst the pre-operative echocardiogram did not alter the orthopaedic management of the patients, apart from one patient who declined surgery; it appeared helpful in the anaesthetic management. In our patients with aortic stenosis, 1 patient with severe aortic stenosis underwent surgery with peripheral nerve blocks plus sedation, 1 patient with critical aortic stenosis had general anaesthesia, 1 patient with mild aortic stenosis had spinal anaesthesia, and 1 patient with severe aortic stenosis refused surgery. Invasive monitoring was used in none of the patients.
10% of patients in the 'echo' group had no valvular heart disease. Interestingly, a recent study showed that a cardiac murmur suggestive of aortic stenosis, diagnosed on admission in 908 hip fracture patients was confirmed by echocardiography in only 30% of cases . Abnormal auscultatory findings can lead to unnecessary referral for echocardiogram.
There is controversy regarding the acceptable delay for surgery in hip fracture patients. A recently published guideline advocated timely and co-ordinated multi-disciplinary care and operative intervention at 36 hours for improved outcomes in hip fracture patients . Early surgery is associated with less pain, improved functional outcome, shorter length of stay in hospital and post-operative complications such as: deep venous thrombosis, pulmonary embolism and pneumonia [11–13].
However, optimisation of hip fracture patients with active medical co-morbidities is also important [14, 15]. A systematic review by Shiga et al  reported that hip fracture surgery delay beyond 48 hours increased the odds of 30-day mortality by 41% and 1 year mortality by 32%. They commented that due to methologic limitations, definitive conclusions could not be drawn. Another study reported that there was no association between delay in hip fracture surgery and mortality after adjustment for medical co-morbidities . There was no significant difference in the length of stay of the hip fracture patients in the 'echo' compared to the 'non echo' group. We found no significant differences in mortality rates at 30 days in the 'echo' compared to the 'non echo' group.