Frequency of Appropriate and Low-Risk Noncardiac Preoperative Stress Testing Across Medical Specialties

Preoperative stress testing in asymptomatic patients is considered rarely appropriate in patients with: (1) moderate to good functional capacity (≥4 metabolic equivalent (METs)), (2) no clinical risk factors, or who are (3) asymptomatic after revascularization, normal stress test, or normal coronary angiography within 1 year. Preoperative stress testing is also not recommended in patients at low risk (<1%) for adverse cardiac events. We investigated the frequency of rarely appropriate and low-risk preoperative stress testing across medical specialties at our institution in asymptomatic patients when applying appropriate use criteria and two different perioperative risk models. We reviewed preoperative stress tests for noncardiac surgeries performed at Hershey Medical Center from January 1, 2012 to December 31, 2014. Perioperative cardiac risk was estimated using the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest risk calculator and the Revised Cardiac Risk Index (RCRI) score. We analyzed 501 preoperative stress tests meeting the study criteria. When applying appropriate use criteria, we found that 336 of 501 studies (67%) were rarely appropriate. When applying the risk score models, 369 of 501 studies (74%) were determined to be low risk by the RCRI (RCRI score ≤1), and 248 of 361 stress tests (69%) were determined to be low risk by the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest risk calculator. Low risk and rarely appropriate preoperative stress testing was common across all ordering specialties reviewed. In conclusion, these findings suggest that preoperative stress testing is broadly overused in asymptomatic patients and that interventions to reduce rarely appropriate and low-risk preoperative stress testing require a multispecialty approach.