Presurgical cardiac stress testing on decline

By Kate Madden Yee, AuntMinnie.com staff writer

October 6, 2020 -- Presurgical cardiac stress testing is on the decline, according to a study published September 30 in JAMA Cardiology. The research suggests that efforts from professional organizations to curb unnecessary healthcare interventions through issuing guidelines has been successful.

Researchers found declines in presurgical use of all kinds of stress testing -- from SPECT myocardial perfusion imaging (MPI), to stress echocardiography and MRI plus electrocardiograms, wrote a team led by Dr. Daniel Rubin of the University of Chicago.

"In the early 2000s, there was significant growth in cardiac imaging that led to increased healthcare costs and concerns from clinicians and [payors] about overuse," the group wrote. "In response to these concerns, a number of interventions occurred in an effort to limit overuse and optimize care, including the development of appropriate use criteria, new clinical practice guidelines, and third-party authorizations programs."

Even with a decline in utilization, however, cardiac stress testing continues to be commonly performed before surgery, even for noncardiac procedures, the group noted. But it doesn't appear to be necessary for most presurgical patients, especially those who do not have any conditions on the Revised Cardiac Risk Index (RCRI). RCRI conditions include heart failure, chronic kidney disease, or a history of diabetes or cerebrovascular or ischemic heart disease.

"The 2007 and 2014 American College of Cardiology/American Heart Association guidelines specify that no patient with zero RCRI conditions warrants preoperative stress testing prior to an intermediate-risk surgery, such as total hip or knee arthroplasty, even those with poor functional status," Rubin and colleagues wrote.

The authors conducted a study that investigated preoperative cardiac stress testing trends and outcomes in a cohort of patients who had the testing between 2004 and 2017 before a total of 801,396 elective total hip (27.9%) or knee (72.1%) replacements. Patients' median age was 62.

The most common cardiac stress test was MPI (84.1%), followed by stress echocardiography (11.3%) and MRI and electrocardiogram (4.6%).

The rate of stress testing increased annually by 0.65% between 2004 and 2006, although it began to decrease annually by 0.71% later in 2006; this decrease rate plateaued at 0.40% annually in 2013. The trend manifested in both Medicare and privately insured patients.

Rates of presurgical cardiac stress testing, 2011-2017
Year Percentage of patients tested
2011 10.6%
2012 10.4%
2013 8.2%
2014 8.6%
2015 5.2%
2016 4.5%
2017 3.8%

Of those patients who had a presurgical cardiac stress test, 49% had no RCRI conditions that would indicate the need for it, the authors wrote. This trend increased over time: In 2004, 44.7% of patients with no RCRI conditions had a stress test, and in 2017, 52.6% did. Yet the researchers also found that incidence of heart attack or cardiac arrest among the patients was low, at 0.24%, with rates of these adverse events not differing between patients with at least one RCRI condition who had a stress test before surgery and patients who didn't have any RCRI conditions (0.60% compared with 0.57%).

"We did not observe any difference in myocardial infarction or cardiac arrest in patients with at least one RCRI condition who underwent stress testing, which suggests [that it] may not contribute to risk stratification in this patient population," the group wrote.

The fact that the proportion of stress tests performed on patients with no RCRI conditions remains high points to an opportunity to curb the practice, thus reducing healthcare costs and streamlining patient care, according to the group.

"Additional investigation is needed to evaluate the optimal patient conditions that would warrant stress testing and whether our results are generalizable to other surgical procedures," the researchers concluded.


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