Preoperative noninvasive cardiac stress testing (NIT) is generally not indicated for asymptomatic patients undergoing intermediaterisk noncardiac surgery, such as elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). Current guidelines and evidence suggest that NIT may be considered only if it will change the management of patients who are scheduled to have higher risk procedures, such as vascular surgery, particularly if they have poor functional capacity and multiple risk factors. Based on our clinical observations, we hypothesize that NIT is overutilized in the preoperative evaluation of patients undergoing TKA or THA.
Using an administrative database, all patients who underwent elective TKA or THA in 2010 at an 805bed tertiary referral teaching hospital and at a 300bed community hospital were identified. Patients were excluded if they were less than 18 years old or if there was no postoperative followup. The records of all patients who had preoperative NIT and of consecutive patients who did not have NIT were reviewed to identify demographic characteristics, clinical factors required to calculate the revised cardiovascular risk index (RCRI) score, and the occurrence of major adverse cardiac events (MACE) and of allcause mortality at 30 days postoperatively. Clinical variables were compared between the two groups using Fisher’s exact, Wilcoxon twosample and Chisquared tests.
850 patients underwent an elective TKA or THA in 2010 at the two clinical sites. 117 (13.8%) patients had preoperative NIT. Around 82% of these tests were ordered in a nonacademic setting and 43% were ordered by internal medicine primary care physicians. A control group of 325 consecutive patients who did not have NIT was used to compare clinical variables. The NIT and control groups were similar in distribution as far as gender and type of surgical procedure. The NIT group was older (mean age, 69.4 years vs 66.6 years, P = 0.024) and had a higher incidence of coronary artery disease (CAD) (14.8% vs. 7.6%, P = 0.031) and insulindependent diabetes mellitus (IDDM) (9.4% vs 4.0%, P = 0.027). The incidence of prior congestive heart failure, cerebrovascular disease or chronic kidney disease was not significantly different between both groups. 83 (70.9%) of the 117 patients who underwent NIT had an RCRI score of 0. There was no incident of MACE in the NIT group and one acute myocardial infarction occurred in the control group. There was one death in each group, both were from pulmonary embolism.
Noninvasive cardiac stress testing is overutilized in patients undergoing elective TKA or THA. Patients who had preoperative NIT are more likely to have been seen in a nonacademic setting. They are more likely to be older or have a history of CAD or IDDM. Postoperative MACE appears to be uncommon after TKA or THA.
To cite this abstract:Muller C, Khoulani D, Paje D, Cerasale M, Gabilondo N, Alsayegh R, Hassan S. Overutilization of Noninvasive Cardiac Stress Testing Prior to Elective Tka or Tha. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97607. https://www.shmabstracts.com/abstract/overutilization-of-noninvasive-cardiac-stress-testing-prior-to-elective-tka-or-tha/. Accessed February 16, 2019.