Stress Testing Before Abdominal Aortic Aneurysm Repair Does Not Prevent Postoperative Cardiac Events

Abstract

Stress testing is commonly used before abdominal aortic aneurysm (AAA) repair. Whether stress testing can prevent cardiac events after AAA repair remains unclear. Our objective was to study national stress test utilization rates and to compare perioperative outcomes between high-use centers and low-use centers. We examined patients who underwent elective endovascular (EVR) or open (OPEN) AAA repair in the Vascular Quality Initiative. We measured utilization rates of stress testing across centers and compared the Vascular Study Group of New England Cardiac Risk Index (VSG CRI) score of patients who underwent preoperative stress tests with those who did not. We determined the rate of major adverse cardiac events (MACEs), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, or death, across centers. We compared MACE and 1-year mortality of centers in the highest quintile of stress test utilization vs those in the lowest quintile. We studied 43,396 EVR patients and 8935 OPEN patients. The median stress test utilization before EVR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OPEN (median, 57.9%; range, 13.0%-86.0%). The mean VSG CRI score for patients who did not undergo stress testing was 5.4 (±2.1) for EVR and 4.8 (±2.1) for OPEN. Patients who underwent stress testing had a slightly higher VSG CRI score (EVR, 5.6 [±2.1]; OPEN, 5.1 [±2.0]; Fig). The rate of MACE was 1.8% after EVR and 11.6% after OPEN. One-year mortality was 4.6% for EVR and 6.6% for OPEN. Centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE (EVR: odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30; OPEN: OR, 1.92; 95% CI, 1.49-2.47) but similar 1-year mortality (EVR: OR, 1.18; 95% CI, 1.02-1.37; OPEN: OR, 0.86; 95% CI, 0.64-1.15) compared with centers in the lowest quintile. The VSG CRI score was not different between high-use (EVR, 5.5 ± 2.1; OPEN, 5.0 ± 2.0) and low-use centers (EVR, 5.5 ± 2.1; OPEN, 4.9 ± 2.0). Stress test utilization before AAA repair varies widely despite similar patient risk profiles. There was no observed reduction in MACE or 1-year mortality among high stress test-using centers. The value of routine stress testing before AAA repair should be reconsidered and used on a more judicious basis.