Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events

Aravind S Ponukumati; Jesse A Columbo; Stanislav Henkin; Jocelyn M Beach; Bjoern D Suckow; Philip P Goodney; Salvatore T Scali; David H Stone

doi:10.1177/1358863X241247537

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events

Vasc Med. 2024 May 6:1358863X241247537. doi: 10.1177/1358863X241247537. Online ahead of print.

Authors

Aravind S Ponukumati^{1

2}, Jesse A Columbo^{1

2}, Stanislav Henkin^{3

4}, Jocelyn M Beach¹, Bjoern D Suckow¹, Philip P Goodney¹, Salvatore T Scali⁵, David H Stone^{1

2}

Affiliations

¹ Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
² Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
³ Department of Surgery, Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
⁴ Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.
⁵ Division of Vascular Surgery, University of Florida, Gainesville, FL, USA.

PMID: 38708691
DOI: 10.1177/1358863X241247537

Abstract

Background: There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines.

Methods: We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE).

Results: Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation.

Conclusions: Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

Keywords: preoperative; quality improvement; risk stratification; stress testing; vascular surgery.