Orthopaedic corticosteroid injections and risk of acute coronary syndrome: a cohort study

Katharine Thomas; Yochai Schonmann

doi:10.3399/bjgp20X713945

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Intra-articular and soft-tissue corticosteroid injection (CSI) is a common treatment for orthopaedic conditions, often performed in primary care. CSIs are believed to have a low incidence of minor local side effects, and no known association with acute ischaemic cardiac events. This study suggests an increased incidence of acute coronary syndrome (ACS) in the week following CSI. The possible association of a common treatment and a life-threatening side effect is of importance to patients, clinicians, and policymakers.

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Table 1.

Patients’ characteristics at the time of orthopaedic visit by injection administration status

	No CSI, N = 57 781	CSI, N = 3075
Mean age, years (SD)	70.7 (10.8)	74.5 (10.3)
N, 50–64 (%)	19 409 (33.6)	634 (20.6)
N, 65–74 (%)	16 225 (28.1)	802 (26.1)
N, ≥75 (%)	22 147 (38.3)	1639 (53.3)
N, Male (%)	19 415 (33.6)	951 (30.9)
N, Obesity^a (%)	12 860 (22.3)	829 (27.0)
N, Smoking^a (%)	21 559 (37.3)	1157 (37.6)
N, Hyperlipidaemia^a (%)	43 989 (76.1)	2452 (79.7)
N, HTN^a (%)	27 684 (47.9)	1760 (57.2)
N, CHF^a (%)	1541 (2.7)	81 (2.6)
N, IHD^a (%)	11 415 (19.8)	747 (24.3)
N, DM^a (%)	13 365 (23.1)	752 (24.5)
N, Mean risk factors^b (SD)	2.7 (1.5)	3.0 (1.4)
N, Mean visits per person (SD)	3.1 (3.4)	5.0 (4.1)
N, First visit n (%)	21 443 (37.1)	504 (16.4)
N, Second visit n (%)	12 360 (21.4)	509 (16.6)
N, Third+ visit (%)	23 978 (41.5)	2062 (67.1)

↵a Based on inclusion in the CHS chronic disease register (see Supplementary Box S1 for details).
↵b Cardiovascular risk factors: obesity, smoking, hyperlipidaemia, hypertension, congestive heart failure, ischaemic heart disease, and diabetes mellitus. CHF = congestive heart failure. CHS = Clalit Health Services. CSI = corticosteroid injection. DM = diabetes mellitus. HTN = hypertension. IHD = ischaemic heart disease. SD = standard deviation.

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Table 2.

Acute coronary Syndrome within 7 days of an orthopaedic visit with a corticosteroid injection

	Exposure	N, No ACS	N, ACS	Crude OR (95% CI)^a	Adjusted OR (95% CI)^a
All	No CSI	57 763	18	-ref-	-ref-
All	CSI	3068	7	7.32 (2.81 to 19.11)	6.62 (2.52 to 17.36)
Aged<65 years	No CSI	19 407	2	-ref- (P= 0.03)	-ref- (P= 0.03)
Aged<65 years	CSI	633	1	15.33 (1.39 to 168.75)	15.49 (1.40 to 171.65)
Aged ≥65 years	No CSI	38 356	16	-ref-	-ref-
Aged ≥65 years	CSI	2435	6	5.91 (2.07 to 16.83)	5.95 (2.10 to 16.81)
Female	No CSI	38 359	7	-ref-	-ref-
Female	CSI	2121	3	7.75 (2.00 to 30.00)	6.42 (1.72 to 23.89)
Male	No CSI	19 404	11	-ref-	-ref-
Male	CSI	947	4	7.45 (1.95 to 28.44)	6.67 (1.72 to 25.86)
No IHD	No CSI	46 363	3	-ref- (P= 0.10)	-ref- (P= 0.07)
No IHD	CSI	2327	1	6.64 (0.69 to 63.87)	6.7 (0.86 to 52.39)
IHD^b	No CSI	11 400	15	-ref-	-ref-
IHD^b	CSI	741	6	6.15 (2.13 to 17.74)	6.27 (2.15 to 18.29)
No smoking	No CSI	36 213	9	-ref-	-ref-
No smoking	CSI	1913	5	10.52 (3.08 to 35.89)	8.42 (2.49 to 28.44)
Smoking^b	No CSI	21 550	9	-ref- (P= 0.07)	-ref- (P= 0.08)
Smoking^b	CSI	1155	2	4.15 (0.90 to 19.16)	4.15 (0.85 to 20.41)
No hyperlipidaemia	No CSI	13 790	2	-ref- (P= 0.05)	-ref-
No hyperlipidaemia	CSI	622	1	11.09 (1.01 to 121.85)	9.03 (0.9 to 90.15)
Hyperlipidaemia^b	No CSI	43 973	16	-ref-	-ref-
Hyperlipidaemia^b	CSI	2446	6	6.74 (2.37 to 19.21)	6.22 (2.18 to 17.75)
No HTN	No CSI	30 092	5	n/a	n/a
No HTN	CSI	1315	0	n/a	n/a
HTN^b	No CSI	27 671	13	-ref-	-ref-
HTN^b	CSI	1753	7	8.5 (3.12 to 23.15)	8.46 (3.08 to 23.21)
No obesity	No CSI	44 910	11	-ref-	-ref-
No obesity	CSI	2241	5	9.11 (2.76 to 30.07)	7.72 (2.36 to 25.24)
Obesity^b	No CSI	12 853	7	-ref- (P= 0.06)	-ref- (P= 0.07)
Obesity^b	CSI	827	2	4.44 (0.92 to 21.43)	4.53 (0.90 to 22.7)
No DM	No CSI	44 405	11	-ref- (P= 0.01)	-ref- (P= 0.02)
No DM	CSI	2320	3	5.22 (1.46 to 18.72)	4.72 (1.28 to 17.32)
DM^b	No CSI	13 358	7	-ref-	-ref-
DM^b	CSI	748	4	10.20 (2.48 to 41.94)	9.55 (2.32 to 39.24)
No CHF	No CSI	56 224	16	-ref-	-ref-
No CHF	CSI	2987	7	8.24 (3.11 to 21.79)	7.52 (2.84 to 19.90)
CHF^b	No CSI	1539	1539	n/a	n/a
CHF^b	CSI	81	0	n/a	n/a
<2 risk factors	No CSI	12 912	1	n/a	n/a
<2 risk factors	CSI	455	0	n/a	n/a
Any two risk factors^c	No CSI	44 851	17	-ref-	-ref-
Any two risk factors^c	CSI	2613	7	7.07 (2.69 to 18.57)	6.92 (2.63 to 18.26)
<3 risk factors	No CSI	25 910	1	n/a	n/a
<3 risk factors	CSI	1083	0	n/a	n/a
Any three risk factors^c	No CSI	31 853	17	-ref-	-ref-
Any three risk factors^c	CSI	1985	7	6.61 (2.51 to 17.37)	6.76 (2.57 to 17.83)

↵a All P-values are <0.001 unless specifically stated otherwise.
↵b Analysis was restricted to patients who were diagnosed with the condition at/before the index orthopaedic visit, as recorded by the Clalit Health Services chronic disease register.
↵c Analysis was restricted to patients diagnosed with any two or three of the above risk factors. ACS = acute coronary syndrome. CHF = congestive heart failure. CSI = corticosteroid injection. DM = diabetes mellitus. HTN = hypertension. IHD = ischaemic heart disease. OR = odds ratio.

Supplementary Data

Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.