Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 933 934
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Editorial
Preoperative Cardiac Stress Testing-
A Thing of the Past?
MORE THAN 300 million patients worldwide undergo
noncardiac surgery each year, with cardiovascular complica-
tions comprising a major proportion of perioperative
morbidity and mortality.1,2 Numerous risk stratification tools
have been developed to predict the likelihood of periopera-
tive complications, but there remain gaps in our understand-
ing of how best to implement these tools to improve patient
evaluation and clinical management and to reduce periopera-
tive complications.
In their study, “Predictive Value of Stress Testing in
Patients Undergoing NonCardiac Surgery,” Kaw et al.3 retro-
spectively investigated the added value of cardiac stress test-
ing in addition to risk stratification with the Revised Cardiac
Risk Index (RCRI) and patient functional capacity defined
using metabolic equivalents (METS) to predict major adverse
cardiac events (MACE). The authors found that both RCRI
and METS were independently predictive of MACE, and
when combined, their predictive power was enhanced.3 How-
ever, the addition of stress testing only marginally improved
risk stratification for postoperative MACE and was associated
with a high prevalence of false negative stress tests.
There is a tendency within modern medicine to err on the
side of caution in regard to patient workup and evaluation.
Likely driven in part by ease and availability of medical diag-
nostic tests, along with fears of medical-legal ramifications in
the event of an adverse outcome, the end result often is exces-
sive diagnostic testing and health care expenditure. The cost
of unnecessary care is staggering—up to $300 billion a year.4
It is estimated that up to 25% of Medicare patients may experi-
ence overuse of low-value services.4 Although ambulatory
care data suggest progress toward increasing care known to be
beneficial to the patient, less progress is evident toward reduc-
ing inappropriate care.5
Similarly, overuse of testing and the associated financial
burden have been demonstrated within preoperative evalua-
tion. Despite efforts by various medical societies to help guide
medical decision making and decrease unnecessary testing
through the development of appropriate use criteria and
DOI of original article: http://dx.doi.org/10.1053/j.jvca.2018.07.020.
https://doi.org/10.1053/j.jvca.2018.09.001
1053-0770/Ó 2018 Elsevier Inc. All rights reserved.
clinical practice guidelines, a high number of tests still are
being performed inappropriately. St. Clair et al. found that
64% of patients undergoing gynecologic surgery underwent
unnecessary preoperative electrocardiograms based on estab-
lished guidelines.6 Furthermore, electrocardiographic abnor-
malities usually did not change clinical management of these
patients. Likewise, Peterson et al. found that of 501 preopera-
tive cardiac stress tests performed for noncardiac surgeries,
74% were determined to be low risk (not requiring testing) by
the RCRI, and 67% rarely were appropriate when appropriate
use criteria were applied.7 Failure to alter clinical management
also has been shown with evaluation through routine preopera-
tive blood work.8
Within the specialty of anesthesiology, what defines
“necessary care” can be viewed through either a narrow or
wide lens. Preoperative testing required to optimize intraoper-
ative care may be much more limited in scope compared
with considering patient outcomes in the larger perspective of
hospital course, discharge, and quality of life. Relatively few
conditions encountered within anesthesia radically alter man-
agement for patients undergoing noncardiac surgeries.
Although certainly not all-inclusive, these include conditions
related to aspiration risk, risk of malignant hyperthermia, need
for neuromonitoring, management of a difficult airway, or car-
diovascular conditions requiring particular hemodynamic con-
siderations such as pulmonary hypertension or severe valvular
lesions. Although extremely common in the elderly popula-
tion, the presence of coronary artery disease (CAD) may have
less of an effect on intraoperative management than the pres-
ence of significant gastroesophageal reflux disease. In fact,
irrespective of cardiac testing, most anesthesiologists would
implement cardiac protective strategies, such as maintaining
adequate coronary perfusion pressure, in any patient with risk
factors for CAD.
However, viewed more broadly, a patient’s perioperative
course contributes toward his or her ultimate outcome, both in
the hospital and after discharge. In this regard, the identifica-
tion of high-yield, cost-effective preoperative studies that help
prognosticate a patient’s long-term outcome is crucial. The
cardiac stress test is a staple of the preoperative assessment.
934 Editorial / Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 933 934
The study by Kaw et al.3 questions the utility of the stress test
in the perioperative setting. It does this not only by showing the
modest additive value of stress testing on top of RCRI and
METS evaluation, but also by citing pre-existing data that pre-
operative coronary revascularization may not improve long-
term mortality in patients with CAD who are undergoing major
noncardiac surgery.3,9 Importantly, however, their study sup-
ports the current guidelines on perioperative cardiovascular
evaluation for patients undergoing elective noncardiac surgery,
which advocate foregoing stress testing for patients other than
those with elevated risk and poor or unknown functional capac-
ity or when testing will affect perioperative decision making.10
Therefore, the question is posed: Is it reasonable to consider
the stress test, a pillar of cardiovascular evaluation, as a test that
adds minimal information to other prognostication tools or a
simple history and physical? Even when acted on periopera-
tively, via coronary interventions or changes in perioperative
management, are we improving long-term morbidity and mor-
tality for patients with CAD? Does the stress test have any util-
ity in current perioperative evaluation for patients undergoing
noncardiac surgery? The Kaw et al. study beckons us to con-
sider not only this question, but, viewed more broadly, the util-
ity of routine preoperative testing and how it may affect patient
optimization and management for a wide range of conditions.
It remains controversial whether preoperative cardiovascu-
lar testing improves outcomes. To this end, future efforts to
define necessary cardiovascular tests should focus on those
that may elicit tangible management changes. The skyrocket-
ing costs of health care in the United States will push increas-
ing selectivity in our ordering of invasive and noninvasive
preoperative studies. The Kaw et al. study casts reasonable
doubt on the utility and necessity of the stress test, and if addi-
tional studies corroborate the results, preoperative stress test-
ing may reasonably become a thing of the past.
Jesse Raiten, MD
Audrey Spelde, MD
Jacob Gutsche, MD
Department of Anesthesiology and Critical Care, University of Pennsylvania,
Philadelphia, PA
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