Frequency and Outcomes of Preoperative Stress Testing in Total Hip and Knee Arthroplasty from 2004 to 2017

Rubin, Daniel; Hughey, Robert; Gerlach, Rebecca M.; Ham, Sandra A.; Ward, R. Parker; Nägele, Peter

doi:10.1001/jamacardio.2020.4311

Cited by 15 publications

(31 citation statements)

References 30 publications

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“…23 Even more recently, a 2020 study on the effectiveness of preoperative cardiac stress testing found no difference in cardiovascular outcomes between patients who did or did not have preoperative testing for their total hip replacement or total knee arthroplasty. 5 They also determined that 30,000 out of every 100,000 cardiac stress tests were unnecessary and did not decrease the frequency of adverse cardiac events.…”

Section: Discussionmentioning

confidence: 99%

Very Low Risk for In-hospital Adverse Outcome Such as ST-elevation or Non-ST-elevation Myocardial Infarction in Patients Undergoing Knee Surgery

Talle

Hashemzadeh²,

Movahed³

2022

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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Background: Knee surgery is a very common surgery. The risk of cardiac events is thought to be low. The goal of this study was to evaluate inpatients adverse outcomes such as ST-elevation myocardial infarction (STEMI) or Non-ST-elevation myocardial infarction in patients undergoing knee surgery. Method: Using the nation inpatient sample database, we evaluated the occurrence of STEMI and Non-STEMI in a very large population. Results: Using 2 random samples from 2005 to 2014, 10 years apart involving 7444 knee surgeries, the occurrence of STEMI and Non-STEMI were very low. In 2005, only 1 STEMI (0.0%) and 4 non-STEMI (0.1%) events occurred in inpatient knee-surgery patients. In the 2014 group, 0 STEMI (0.0%) and 5 non-STEMI (0.16%) events occurred in inpatient knee-surgery patients. Overall, STEMI or non-STEMI events occurred in 0.13% of inpatient kneesurgery procedures. Conclusions: Inpatients' adverse outcome of patients undergoing knee surgery is very low suggesting that extensive cardiac workup for knee surgery may not be warranted.

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Section: Discussionmentioning

confidence: 99%

Very Low Risk for In-hospital Adverse Outcome Such as ST-elevation or Non-ST-elevation Myocardial Infarction in Patients Undergoing Knee Surgery

Talle

Hashemzadeh²,

Movahed³

2022

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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“…22 23 A recent cross-sectional analysis of claims data from patients who had total hip or knee arthroplasty also identified decreasing testing frequency over a similar period. 24 Our cohort study begins with a visit to a preoperative risk assessment clinic, incorporates detailed clinical data and is not limited to patients who have completed orthopaedic surgery. Our analysis, thus, extends previous understanding by showing that the reduction is not limited to orthopaedic procedures, not a result of selecting patients not referred for stress testing for elective surgery, and not consequent to lower predicted cardiac risk.…”

Section: Discussionmentioning

confidence: 99%

Variation in preoperative stress testing by patient, physician and surgical type: a cohort study

et al. 2021

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ObjectivesTo describe variation in and drivers of contemporary preoperative cardiac stress testing.SettingA dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018.ParticipantsA cohort of 118 552 adult patients seen by 104 physicians across 159 795 visits to a preoperative risk assessment and optimisation clinic.Main outcomeReferral for stress testing before major surgery, including nuclear, echocardiographic or electrocardiographic-only stress testing, within 30 days after a clinic visit.ResultsA total of 8303 visits (5.2%) resulted in referral for preoperative stress testing. Key patient factors associated with preoperative stress testing included predicted surgical risk, patient functional status, a previous diagnosis of ischaemic heart disease, tobacco use and body mass index. Patients living in either the most-deprived or least-deprived census block groups were more likely to be tested. Patients were tested more frequently before aortic, peripheral vascular or urologic interventions than before other surgical subcategories. Even after fully adjusting for patient and surgical factors, provider effects remained important: marginal testing rates differed by a factor-of-three in relative terms and around 2.5% in absolute terms between the 5th and 95th percentile physicians. Stress testing frequency decreased over the time period; controlling for patient and physician predictors, a visit in 2008 would have resulted in stress testing approximately 3.5% of the time, while a visit in 2018 would have resulted in stress testing approximately 1.3% of the time.ConclusionsIn this large cohort of patients seen for preoperative risk assessment at a single health system, decisions to refer patients for preoperative stress testing are influenced by various factors other than estimated perioperative risk and functional status, the key considerations in current guidelines. The frequency of preoperative stress testing has decreased over time, but remains highly provider-dependent.

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Section: Introductionmentioning

confidence: 99%

“…Several studies have used administrative claims data to investigate the relationship between RCRI scores, preoperative testing, and/or MACE during the perioperative period ( 8 , 9 , 10 , 11 , 12 , 13 ). Although there are limited data on patients with SLE undergoing surgery, prior studies showed that these patients had an increased risk of mortality during hospitalization after surgical procedures ( 14 , 15 , 16 ).…”

Section: Introductionmentioning

confidence: 99%

Postoperative Major Adverse Cardiac Events in Patients With Systemic Lupus Erythematosus

Bruera

Lei

Blau

et al. 2022

ACR Open Rheumatology

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Objectives Patients with systemic lupus erythematosus (SLE) have a high risk of cardiovascular disease that could potentially increase postoperative major adverse cardiac events (MACE). We determined the rate of MACE in patients with SLE undergoing noncardiac surgery using national claims‐based data. Methods This was a retrospective cohort study using Optum Clinformatics Data Mart from 2007 to 2020. We identified a cohort of patients with SLE who had undergone noncardiac surgeries using Current Procedural Terminology codes. We also identified two control cohorts without SLE, one with diabetes mellitus (DM) and one without DM. After matching cases and controls by age and sex, the odds of MACE were estimated using multivariable logistic regression models also including race and the Revised Cardiac Risk Index (RCRI) scores. We also examined use of preoperative cardiac testing. Results We identified 4750 patients with SLE, 496,381 DM controls, and 1,484,986 non‐DM controls. After matching, the odds ratio (OR) for MACE in patients with SLE versus non‐DM controls was 1.51 (95% confidence interval 1.09‐2.08), which decreased after adjustment for RCRI score (OR: 0.97, 95% confidence interval 0.7‐1.36). No significant differences were observed in the incidence of MACE between patients with SLE and DM controls (0.82 vs 1.04, P = 0.16). High‐risk patients with SLE (RCRI score of ≥3) were less likely to receive preoperative cardiac testing than non‐DM controls (42.7% vs 35.1%, P < 0.05). Conclusion Patients with SLE have an increased risk of postoperative MACE, which is driven by increased RCRI scores. Concerningly, high‐risk patients received less cardiac testing 2 months before surgery than non‐DM controls.

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Frequency and Outcomes of Preoperative Stress Testing in Total Hip and Knee Arthroplasty from 2004 to 2017

Cited by 15 publications

References 30 publications

Very Low Risk for In-hospital Adverse Outcome Such as ST-elevation or Non-ST-elevation Myocardial Infarction in Patients Undergoing Knee Surgery

Very Low Risk for In-hospital Adverse Outcome Such as ST-elevation or Non-ST-elevation Myocardial Infarction in Patients Undergoing Knee Surgery

Variation in preoperative stress testing by patient, physician and surgical type: a cohort study

Postoperative Major Adverse Cardiac Events in Patients With Systemic Lupus Erythematosus

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