Choosing Wisely:

Don’t obtain baseline diagnostic cardiac testing (transthoracic/esophageal echocardiography) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., coronary artery disease, valvular disease) undergoing low or moderate risk noncardiac surgery.

Rationale and Comments: Advances in cardiovascular medical management, particularly the introduction of perioperative beta-blockade and improvements in surgical and anesthetic techniques, have significantly decreased operative morbidity and mortality rates in noncardiac surgery. Surgical outcomes continue to improve causing the mortality rate of major surgeries to be low and the need for revascularization minimal. Consequently, the role of preoperative cardiac stress testing has been reduced to the identification of extremely high-risk patients, for instance, those with significant left main disease for which preoperative revascularization would be beneficial regardless of the impending procedure. In other words, testing may be appropriate if the results would change management prior to surgery, could change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform.
Sponsoring Organizations:
  • American Society of Anesthesiologists
  • Sources:
  • American Society of Anesthesiologists guidelines
  • Disciplines:
  • Cardiovascular
  • Surgical
  • References: • Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich DG, Rice LJ, Roizen MF, Twersky RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012 Mar;116(3):522-38.
    • Miller AL, Beckman JA. (2013). Which patient should have a preoperative cardiac evaluation (stress test)? In: Fleisher L. Evidence-based practice of anesthesiology (3rd ed., pp. 61–70). Philadelphia (PA): Elsevier Saunders.
    • Schiefermueller J, Myerson S, Handa AI. Preoperative assessment and perioperative management of cardiovascular risk. Angiology. 2013;64(2):146-50.
    • Sheffield KM, McAdams PS, Benarroch-Gampel J, Goodwin JS, Boyd CA, Zhang D, Riall TS. Overuse of preoperative cardiac stress testing in medicare patients undergoing elective noncardiac surgery. Ann Surg. 2013; 257(1):73-80.
    • Almanaseer Y, Mukherjee D, Kline-Rogers EM, Kesterson SK, Sonnad SS, Roges B, Smith D, Furney S, Ernst R, McCort J, Eagle KA. Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes. Cardiology. 2005;103(1):24-9.
    • Cinello M, Nucifora G, Bertolissi M, Badano LP, Fresco C, Gonano N, Fioretti PM. American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving favorable outcome. J Cardiovasc Med. 2007;8(11):882-8.
    • Augoustides JG, Neuman MD, Al-Ghofaily L, Silvay G. Preoperative cardiac risk assessment for noncardiac surgery: defining costs and risks. J Cardiothorac Vasc Anesth. 2013;27(2):395-9.
    • Falcone RA, Nass C, Jermyn R, Hale CM, Stierer T, Jones CE, Walters GK, Fleisher LA. The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective randomized trial. J Cardiothorac Vasc Anesth. 2003;17(6):694-8.
    • Poldermans D, Boersma E. Beta-blocker therapy in noncardiac surgery. N Engl J Med. 2005;353:412-4.

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