Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Nov:90:111158.
doi: 10.1016/j.jclinane.2023.111158. Epub 2023 Jul 5.

Consequences of preoperative cardiac stress testing-A cohort study

Matthew A Pappas  1 , Andrew D Auerbach  2 , Michael W Kattan  3 , Eugene H Blackstone  4 , Michael B Rothberg  5 , Daniel I Sessler  6
Affiliations

Consequences of preoperative cardiac stress testing-A cohort study

Matthew A Pappas et al. J Clin Anesth. 2023 Nov.

Abstract

Objective: To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery.

Design: A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018.

Setting: A large integrated health system.

Patients: Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery.

Measurements: To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality.

Main results: In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1-12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8-9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9-9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75-0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1-33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses.

Conclusions: Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.

Keywords: Cardiovascular; Diagnostic techniques; Outcome and process assessment; Perioperative care; Preoperative period.

PubMed Disclaimer

Conflict of interest statement

Declaration of Competing Interest None.

Figures

Figure 1.
Figure 1.
Patient flow diagram.
Figure 2.
Figure 2.
Kaplan-Meier failure estimates in the year following an IMPACT clinic visit, by completion of preoperative cardiac stress testing.
Figure 3.
Figure 3.
Kaplan-Meier failure estimates in the year following an IMPACT clinic visit, by binned probability of preoperative cardiac stress testing.
See this image and copyright information in PMC

Comment in

References

    1. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;130:2215–45. 10.1161/CIR.0000000000000105. - DOI - PubMed
    1. Ganguli I, Lupo C, Mainor AJ, Raymond S, Wang Q, Orav EJ, et al. Prevalence and Cost of Care Cascades after Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019;179:1211–9. 10.1001/jamainternmed.2019.1739. - DOI - PMC - PubMed
    1. Bouck Z, Calzavara AJ, Ivers NM, Kerr EA, Chu C, Ferguson J, et al. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med 2020;180:973–83. 10.1001/jamainternmed.2020.1611. - DOI - PMC - PubMed
    1. Bhatia RS, Bouck Z, Ivers NM, Mecredy G, Singh J, Pendrith C, et al. Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination. JAMA Intern Med 2017;177:1326–33. 10.1001/JAMAINTERNMED.2017.2649. - DOI - PMC - PubMed
    1. Wijeysundera DN, Beattie WS, Elliot RF, Austin PC, Hux JE, Laupacis A. Noninvasive cardiac stress testing before elective major non-cardiac surgery: Population based cohort study. BMJ 2010;340:252. 10.1136/bmj.b5526. - DOI - PMC - PubMed

Publication types