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Multicenter Study
. 2016 Sep 5;16(1):173.
doi: 10.1186/s12872-016-0357-5.

Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study

Emily B Levitan  1   2 , Laura A Graham  3   4 , Javier A Valle  5 , Joshua S Richman  4   6 , Robert Hollis  4   6 , Carla N Holcomb  4   6 , Thomas M Maddox  5   7 , Mary T Hawn  4   8
Affiliations
Multicenter Study

Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study

Emily B Levitan et al. BMC Cardiovasc Disord. .

Abstract

Background: Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.

Methods: Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000-2012.

Results: Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.

Conclusions: Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.

Keywords: Echocardiography; Major adverse cardiac events; Surgery.

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Figures

Fig. 1
Fig. 1
Facility variation in use of pre-operative echocardiography in the Veterans Affairs Healthcare System. Smoothed distribution of pre-operative echocardiography rates by hospital. Of the 146 Veterans Affairs hospitals, 117 with at least 25 surgeries in the overall population, 87 with at least 25 surgeries in the population with recent MI, HF, or VHD, and 117 with at least 25 surgeries in the population without recent MI, HF, or VHD were included
Fig. 2
Fig. 2
Association between hospital-level variation in pre-operative echocardiography and post-operative major adverse cardiac events. MACE: Major adverse cardiac event, HF: Heart failure, VHD: Valvular heart disease, MI: Myocardial infarction. Quartile ranges: Overall population unadjusted ≤9.72 %, 10.00–14.06 %, 14.19–18.84 %, and ≥19.01 %; Overall population case mix-adjusted ≤12.70 %, 12.75–14.20 %, 14.25–15.97 %, and ≥16.00 %; Patients with heart failure, valvular heart disease, recent myocardial infarction unadjusted ≤18.18 %, 18.46–24.86 %, 25.00–30.43 %, and ≥31.11 %; Patients with heart failure, valvular heart disease, recent myocardial infarction case mix-adjusted ≤23.45 %, 23.47–25.11 %, 25.11–27.23 %, and ≥27.49 %; Patients without heart failure, valvular heart disease, recent myocardial infarction unadjusted ≤6.06 %, 6.11–9.85 %, 9.88–12.94 %, and ≥12.95 %; Patients without heart failure, valvular heart disease, recent myocardial infarction case mix-adjusted ≤9.04 %, 9.04–9.67 %, 9.67–10.52 %, and ≥10.53 %
Fig. 3
Fig. 3
Association between patient level pre-operative echocardiography and post-operative major adverse cardiac events. MACE: Major adverse cardiac event, HF: Heart failure, VHD: Valvular heart disease, MI: Myocardial infarction. Models included a random intercept for hospital and adjusted for echocardiogram during the 3 to 12 months prior to surgery, age at surgery, recent myocardial infarction, history of heart failure, history of chronic kidney disease, history of arrhythmia, surgery case status, surgery admission status, work relative value unit, year of surgery, procedure type, and an indicator for whether the surgery was a high risk procedure
See this image and copyright information in PMC

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