Heart Risks With Joint Replacement Surgery

By Emily Delzell

If joint damage from arthritis means you live with daily pain or aren’t as active as you want to be, you may be thinking about surgery to replace that worn-out knee or hip. Total joint replacement surgery often relieves pain and returns some of the mobility and function lost to arthritis.

But these procedures also come with some risks. Among them are increased risks of heart trouble, particularly in the first 90 days after surgery.

“These are major surgeries, and any major surgery puts a large stress on the body and carries a risk of cardiovascular events afterward,” says Claudette M. Lajam, MD, an orthopedic surgeon at NYU Langone Health in New York City.

Cardiac events that can happen after total joint replacement include heart attack, cardiac arrest and arrhythmia, or an irregular heartbeat.

What Causes the Risks

The effects of anesthesia along with blood loss, low blood oxygen and other issues that can happen during surgery all stress your cardiovascular system, which raises the risk of heart problems.

If you have other conditions that increase the risk of cardiovascular problems, such as diabetes or high blood pressure, complications are more likely, says rheumatologist Linda A. Russell, MD, director of perioperative medicine at the Hospital for Special Surgery in New York City.

“This is particularly true if the diabetes or high blood pressure isn’t well controlled,” she says. “In addition, people with an inflammatory arthritis, like rheumatoid arthritis, are already at greater risk for cardiovascular disease, and they would also be at greater risk for cardiovascular events around the time of surgery.”

These factors can also increase the risk for cardiovascular events around the time of joint surgery:

• Smoking
• Obesity
• High cholesterol
• Coronary artery disease
• A previous heart attack or stroke
• Being 60 or older

Overall, cardiovascular risks with joint surgery are fairly low. Rates of cardiovascular complications in people with osteoarthritis after hip and knee replacement ranged from .07% to 3%, according to a 2019 review of studies published in the Journal of Orthopedic Surgery and Research.

But as Drs. Lajam and Russell point out, these risks rise when you have other conditions.

Some types of joint surgery, such as having both knees or both hips replaced at the same time, may also create more risk to your heart than smaller surgeries, says Dr. Russell.

“This is due to the longer operating time, which means more time under anesthesia and more blood loss and other issues,” she says. “For similar reasons I would say the risks with total hip and total knee replacement are probably a little bit greater than those for total shoulder, elbow or wrist replacement. Those are smaller surgeries.”

Blood Clot Complications

When joint replacement involves the hip or knee, there’s also the chance of developing blood clots. These can occur in the legs as a deep vein thrombosis (DVT), which can break off and travel to the lungs, as pulmonary embolism, blocking blood flow. Like heart attacks, they can be fatal, and the odds of blood clots forming are much higher than for cardiovascular events. In a 2020 study published in Thrombosis Research, 13% of people who had total hip replacement had a diagnosed DVT or pulmonary embolism in the first 10 days after surgery.

It’s typically immobility or injury to blood vessels that can lead to these clots. When you’re lying on the operating table during surgery or in bed recovering, it’s easier for blood to pool and form clots. Cutting through blood vessels also raises the risk of blood clots, says Dr. Lajam. 

These conditions add to the risk of blood clots forming:

• A body mass index higher than 40 kg/m2
• Stroke in the previous three months
• Chronic obstructive pulmonary disease
• Coronary artery disease
• Peripheral vascular disease
• Previous DVT or pulmonary embolism
• Inherited blood clotting disorder
• Use of birth control pills or hormone replacement therapy

Lower Your Risks

Before joint replacement surgery, your orthopedic surgeon will check your health and medical history to see if you have increased risks for cardiovascular events, blood clots or other issues.

If you can’t walk four blocks or up two flights of stairs without shortness of breath or chest pressure or pain, you may need additional tests of your heart function to see if you have the needed cardiovascular reserve for surgery, Dr. Russell says.

If you don’t, your orthopedic surgeon may ask you to work with a cardiologist to improve your cardiovascular health.

“For people with diabetes, we test to make sure that disease is well-controlled before surgery,” Dr. Russell says. “If it’s not, then the patient needs to work with their endocrinologist to change their medications to get the diabetes under better control.” She notes that diabetes is not only linked to greater cardiovascular risk, but to a greater risk of infection at the surgical site. 

Because joint replacement surgeries are elective, there’s time to optimize your health. You can lower the risks of certain complications and improve post-surgery recovery by taking these measures.

• Work with your rheumatologist to bring inflammatory arthritis under good control.
• Lose weight.
• Stop smoking.
• If you are out of shape or frail, ask your doctor about preoperative physical therapy to help you get stronger before surgery.
• Take care of any dental problems before surgery. Dental infections can spread through your bloodstream to your new joint.

“Ideally, people should work with their doctors in the month or two before joint replacement surgery to get as healthy as possible beforehand, which can lower their risk for complications,” Dr. Russell says. 

A Boost for Heart Health?

Some research has found joint surgery protects the heart over time. That makes sense, because once your pain is gone, activity is easier, and exercise can improve heart health.

However, those studies did not include cardiac events that happened in the month right after joint surgery, when these complications are most likely to happen, says Yuqing Zhang, director of Epidemiological and Biostatistical Methods at Massachusetts General Hospital and professor in residence in medicine at Harvard Medical School in Boston.

He is also the senior author of a 2015 study of about 20,000 people with OA who had total hip or total knee replacement between 2000 and 2012. Published in Arthritis & Rheumatology, it found that heart attacks were eight times more likely in the month after total knee replacement and four times more likely after total hip replacement. 

“According to our research, the risk of heart attack did decrease one year after surgery. However, this decreased risk did not completely compensate for the increased risk of heart attack that we found right after total knee or hip replacement,” Dr. Zhang says.

Reviewed 2/18/22