Preoperative Cardiac Stress Testing Research Articles

Role of Preoperative Cardiac Stress Testing in Patients with Chronic Limb Threatening Ischemia

Role of Preoperative Cardiac Stress Testing in Patients with Chronic Limb Threatening Ischemia

Abstract 14618: Comparative Outcomes of Elective Endovascular Abdominal Aortic Aneurysm Repair in Patients With Preoperative Cardiac Stress Testing

Introduction: The use of cardiac stress testing (CST) before endovascular abdominal aortic aneurysm (EVAR) repair is controversial. While prior research has explored the utility of CST before EVAR, EVAR outcomes in patients with different CST results have not been studied. The objective of this study is to evaluate EVAR outcomes in patients with abnormal CST. Hypothesis: Patients with abnormal CST before EVAR have inferior outcomes compared to patients with normal CST. Methods: The Vascular Quality Initiative (VQI) database for EVAR was reviewed. Patients who underwent CST prior to elective EVAR were included. In VQI, abnormal CST is defined as having ischemia, infarction, or both ischemia and infarction (BII). Outcomes of patients with normal and abnormal CST were compared, including a subgroup analysis of CST abnormalities. Results: A total of 19,964 patients were included and 23.7% (4,723) had abnormal CST. Patients with abnormal CST were more commonly males with comorbidities. Patients with abnormal CST had significantly more perioperative complications including MACE and one-year mortality compared to patients with normal CST. ( Table ) Regression analysis revealed that abnormal CST was independently associated with increased perioperative MACE (OR=1.59 [1.28-1.97]) and one-year mortality (HR=1.11 [1.00-1.23]). Subgroup analysis of patients with abnormal CST showed that patients with BII had significantly more perioperative MACE (6.8% vs 4.1%, P =0.002) and mortality (1.1% vs 0.4%, P =0.040) compared to patients with either ischemia or infarction. BII was independently associated with MACE (OR=1.62 [1.06-2.41]) and 30-day mortality (OR=3.28 [1.21-8.16]) compared to either abnormality. Conclusions: Patients with abnormal CST have worse outcomes after elective EVAR compared to patients with normal CST, particularly patients with BII. CST is a useful tool for perioperative and long-term risk stratification in patients undergoing elective EVAR.

Consequences of preoperative cardiac stress testing—A cohort study

ObjectiveTo understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. DesignA retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. SettingA large integrated health system. PatientsPatients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. MeasurementsTo assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. Main resultsIn causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1–12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8–9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9–9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75–0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1–33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. ConclusionsPreoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

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

Cardiac stress testing is often performed prior to noncardiac surgery, although trends in use of preoperative stress testing and the effect of testing on cardiovascular outcomes are currently unknown. To describe temporal trends and outcomes of preoperative cardiac stress testing from 2004 to 2017. Cross-sectional study of patients undergoing elective total hip or total knee arthroplasty from 2004 to 2017. Trend analysis was conducted using Joinpoint and generalized estimating equation regression. The study searched IBM MarketScan Research Databases inpatient and outpatient health care claims for private insurers including supplemental Medicare coverage and included patients with a claim indicating an elective total hip or total knee arthroplasty from January 1, 2004, to December 31, 2017. Elective total hip or knee arthroplasty. Trend in yearly frequency of preoperative cardiac stress testing. The study cohort consisted of 801 396 elective total hip (27.9%; n = 246 168 of 801 396) and total knee (72.1%; 555 228 of 801 396) arthroplasty procedures, with a median age of 62 years (interquartile range, 57-70 years) and 58.1% women (n = 465 545 of 801 396). The overall rate of stress testing during the study period was 10.4% (n = 83 307 of 801 396). The rate of stress tests increased 0.65% (95% CI, 0.09-1.21; P = .03) annually from quarter (Q) 1 of 2004 until Q2 of 2006. A joinpoint was identified at Q3 of 2006 (95% CI, 2005 Q4 to 2007 Q4) when preoperative stress test use decreased by -0.71% (95% CI, -0.79% to 0.63%; P < .001) annually. A second joinpoint was identified at the Q4 of 2013 (95% CI, 2011 Q3 to 2015 Q3), when the decline in stress testing rates slowed to -0.40% (95% CI, -0.57% to -0.24%; P < .001) annually. The overall rate of myocardial infarction and cardiac arrest was 0.24% (n = 1677 of 686 067). Rates of myocardial infraction and cardiac arrest were not different in patients with at least 1 Revised Cardiac Risk Index condition who received a preoperative stress test and those who did not (0.60%; n = 221 of 36 554 vs 0.57%; n = 694 of 122 466; P = .51). The frequency of preoperative stress testing declined annually from 2006 through 2017. Among patients with at least 1 Revised Cardiac Risk Index condition, no difference was observed in cardiovascular outcomes between patients who did and did not undergo preoperative testing.

Preoperative Cardiac Stress Testing in Patients Undergoing Vascular Surgery: Preliminary Results of a Systematic Review

Introduction: Coronary artery disease (CAD) is a major cause of perioperative morbidity and mortality in patients undergoing vascular surgery. Several tests have been used to assess risk of postoperative cardiac complications. In this systematic review we compared the prognostic accuracy of preoperative cardiac stress tests in predicting postoperative cardiac events in patients undergoing vascular surgery. Methods: A study protocol was designed in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and registered with the International Prospective Register of Systematic Reviews (CRD42019117846). A search of Medline, Embase, Scopus, CINAHL and the Cochrane library databases was conducted to identify studies correlating postoperative cardiac events of patients undergoing vascular surgery to preoperative cardiac stress tests between 1998 and 2018. For the purpose of this review, only pharmacological stressing agents were included. Quality was assessed using the Newcastle-Ottawa scores (NOS). Sensitivity and specificity of each test was calculated from published results. Summary receiver operator characteristic (SROC) curve and forest plots were used to compare different tests. Results: A total of 17 studies (3182 patients) were included. The mean age was 67±3 years and 82% were male. Twelve studies (71%) were prospective and 13 (76%) had a Newcastle-Ottawa scale score ³7. Seven studies used stress echocardiography (SE), 8 myocardial perfusion imaging (MPI) and 2 studies compared SE and MPI. With regards to predicting postoperative cardiac events, MPI and SE had a sensitivity of 70% (95% confidence interval [CI] 44% to 83%) and 49% (95% CI 32% to 70%) respectively whilst specificity was 60% (95% CI 45% to 79%) and 85% (95% CI 74% to 87%) respectively. Conclusion: Overall prognostic accuracy of cardiac stress tests for postoperative cardiac events after vascular surgery remains modest. Further research is required in vascular surgery patients using newer techniques and modalities that have been shown to have higher diagnostic accuracy of predicting CAD. Disclosure: Nothing to disclose

Anticipated Rates and Costs of Guideline-Concordant Preoperative Stress Testing.

Current guidelines recommend that patients have preoperative assessment of cardiac risk and functional status, and that patients at "elevated" cardiac risk with poor or unknown functional status be referred for preoperative stress testing. Little is known about current rates of testing or resultant medical costs. We set out to estimate the expected rates of preoperative stress testing and resultant costs if physicians in the United States were to follow current guidelines and to investigate differences that would arise from 2 risk prediction methods included in current guidelines. We applied 2 risk prediction tools (Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest) included in current American College of Cardiology/American Heart Association guidelines to a multicenter prospective registry of patients undergoing surgery in the United States in 2009. We then calculated expected rates of preoperative cardiac stress testing if physicians were to follow American College of Cardiology/American Heart Association guidelines, expected nationwide direct medical expenditures that would result (in 2017 US dollars), and agreement beyond chance between the 2 risk prediction tools. Current guidelines recommend considerable spending on preoperative stress testing. Guideline-recommended spending would differ substantially depending on the risk prediction tool used and the reliability of the functional status assessment. Rates of testing and resultant spending are likely much greater among patients at "elevated" risk, compared with patients at "low" risk. Two guideline-recommended risk assessment tools, Revised Cardiac Risk Index and Myocardial Infarction or Cardiac Arrest, have poor agreement beyond chance across the currently recommended risk threshold. Preoperative stress testing is likely a considerable source of medical spending, despite unproven benefit. Which perioperative risk assessment tool clinicians should use, what risk thresholds are appropriate for patient selection, and the reliability of the functional status assessment all warrant further attention.

The association of preoperative cardiac stress testing with 30-day death and myocardial infarction among patients undergoing kidney transplantation.

BackgroundAlthough periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI.MethodsUsing the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation.ResultsIn the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79–1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89–1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71–1.32; P = 0.84).ConclusionStress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation.

Preoperative Cardiac Stress Testing in the Southern California Vascular Outcomes Improvement Collaborative

The objective of this study was to examine the use of preoperative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe). A retrospective review was performed on data in all modules of the So Cal VOICe from September 2012 through May 2016. PCST was defined as stress echocardiogram or nuclear stress test. A new postoperative myocardial infarction (MI) was defined as troponin elevation and/or electrocardiogram/imaging changes with or without ischemic symptoms. Only elective cases in patients with asymptomatic cardiac status were included in the study. During the study period, 3,063 procedures meeting the inclusion criteria were performed in 7 registries: carotid endarterectomy (CEA), carotid artery stent, thoracic endovascular aneurysm repair, infrainguinal bypass (Infra), endovascular aneurysm repair (EVAR), suprainguinal bypass (Supra), and open abdominal aortic aneurysm repair (OAAA). PCST varied across registries from 17% in PVI to 62% in OAAA. PCST in CEA varied across 9 institutions from 10% to 79%. PCST in EVAR varied across 7 institutions from 14% to 83%. PCST in Infra varied across 4 institutions from 10% to 57%. Of the 12 patients across all registries who had a new MI, 6 had PCST, one of which was abnormal. The incidence of PCST varies widely across registries and institutions in the So Cal VOICe. Despite the wide variation, the incidence of new postoperative MI is exceptionally low. Further studies should evaluate the cost-effectiveness of the PCST practices and future quality improvement efforts should focus on standardization of indications for PCST.

Pre-operative Cardiac Stress Testing in the So Cal VOICe

Peri-operative guidelines from the American College of Cardiology/American Heart Association recommend that for patients undergoing elective vascular surgery, pharmacologic stress testing be performed in patients with poor or unknown functional capacity in which further testing will impact decision making or perioperative care. The objective of this study is to examine the use of pre-operative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe).

Cardiac Stress Testing during Workup for Abdominal Aortic Aneurysm Repair Is Not Associated with Improved Patient Outcomes

Cardiac stress testing (CST) is commonly used to help determine whether patients with abdominal aortic aneurysms (AAAs) are better candidates for open versus endovascular repair, although it is unknown whether the use of CST achieves its goal of optimizing patient selection and postoperative outcomes. We retrospectively identified 3,635 patients in the Vascular Quality Initiative database (2010-2012) with an AAA ≥5.0cm who were candidates for either open or endovascular AAA repair. The Vascular Study Group Cardiac Risk Index (VSG-CRI) was used to stratify patient risk. We applied generalized estimating equations with inverse probability weighting (IPW) to adjust for patient factors and hospital-level CST utilization to evaluate the effect of CST on composite of 30-day major adverse cardiac events or mortality (MACE-M) following AAA repair. CST was utilized in 1,627 (45%) patients during AAA workup, including 451 of 794 (57%) patients selected for open repair and 1,176 of 2,841 (41%) selected for endovascular repair. After IPW, the use of CST was not associated with the probability of patients receiving open versus endovascular repair (OR: 1.00; 95% CI: 0.77-1.32). As compared to patients without CST during AAA workup, adjusted analyses revealed that CST utilization was not associated with improved MACE or mortality outcomes following AAA repair. Among patients receiving CST, an abnormal CST was not significantly associated with selection of open versus endovascular repair or with postoperative outcomes after adjustment for the VSG-CRI score. Similar results were found for patients with either low or high VSG-CRI scores. Utilization of CST during workup for AAA is not associated with procedure selection and improved outcomes. Identifying risk factors for individuals who would benefit from preoperative CST before AAA repair will help reduce health care utilization and improve postoperative outcomes.

Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis

Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization on diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients do and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO). From 1998 to 2013 at a single institution, 166 CEA patients were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing, degree of stenosis, smoking status, and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P < .10) to determine independent (P < .05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts. There were 32 black patients and 134 white patients studied; the mean TDO was 78 ± 17 days vs 33 ± 3 days, respectively (P < .001). In addition to the need for preoperative cardiac stress testing, black race was the only variable that demonstrated a trend with (P < .10) or was an independent risk factor for (P < .05) prolonged TDO among all patients (B = 42 days; P < .001) and within the symptomatic (B = 35 days; P = .08) and asymptomatic (B = 35 days; P = .003) cohorts. On Kaplan-Meier analysis, black patients in each stratum of symptomatology (all, symptomatic, and asymptomatic patients) experienced prolonged TDO (log-rank, P < .03 for all three groups). Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.

Overuse of Preoperative Cardiac Stress Testing in Medicare Patients Undergoing Elective Noncardiac Surgery

To determine the frequency and predictors of cardiac stress testing before elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation. The American College of Cardiology/American Heart Association guidelines indicate that patients without class I (American Heart Association high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery. We used 5% Medicare inpatient claims data (1996-2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urological, or orthopedic procedures (N = 211,202). We examined the use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N = 74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing. Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N = 2803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (P < 0.0001). A multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female sex [odds ratio (OR) 1.11; 95% CI: 1.02-1.21], presence of other comorbidities [OR 1.22; 95% confidence interval (CI): 1.09-1.35], high-risk procedure (OR 2.42; 95% CI: 2.04-2.89), and larger hospital size (OR 1.17; 95% CI: 1.03-1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR 1.24; 95% CI: 1.05-1.45) were also more likely to receive stress tests. In a 5% sample of Medicare claims data, 2803 patients underwent preoperative stress testing without any indications. When these results were applied to the entire Medicare population, we estimated that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications has increased significantly over time.

Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study

Objective To determine the association of non-invasive cardiac stress testing before elective intermediate to high risk non-cardiac surgery with survival and hospital stay.Design Population based retrospective cohort study.Setting Acute care...

Reducing cardiac risk in non-cardiac surgery: evidence from the DECREASE studies

Ischaemic cardiac events are a major cause of perioperative morbidity and mortality in non-cardiac surgery; 10–40% of the perioperative deaths are due to myocardial infarction (MI). Drugs that influence myocardial oxygen balance (e.g. beta-blockers) or improve plaque stability (e.g. statins) would be expected to reduce perioperative MI. Evidence for the benefit of beta-blockers in high-risk patients undergoing non-cardiac surgery comes from various studies including the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) study, in which perioperative bisoprolol significantly reduced short- and long-term cardiac death and MI. DECREASE IV found that bisoprolol also significantly reduced 30-day cardiac death and MI in intermediate-risk patients, with a non-significant trend towards a beneficial effect of fluvastatin XL. DECREASE III showed that in high-risk patients undergoing major vascular surgery, fluvastatin XL reduced myocardial ischaemia and the combined endpoint of cardiovascular death and MI. DECREASE II showed that patients identified as intermediate risk on the basis of clinical assessment did not need pre-operative echocardiographic cardiac stress testing, provided that they received bisoprolol to maintain tight heart rate control. DECREASE V found that in high-risk patients with extensive stress-induced ischaemia, coronary revascularization (added to tight heart rate control with bisoprolol) did not produce any additional reduction in death and MI.

Peripheral Vascular Surgery Using Targeted Beta Blockade Reduces Perioperative Cardiac Event Rate

Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective. A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively. The primary end point was a composite of adverse cardiac outcomes. A comparison was made with historical controls who received selective stress testing and selective nontargeted beta blockade. One hundred consecutive patients were prospectively enrolled, and 80 retrospective controls were identified. There were no differences between groups with respect to median revised cardiac index (RCI; 0 versus 1). In the retrospective group, 14% underwent preoperative cardiac stress testing versus none in the prospective group (p=0.0002). Nontargeted beta blockade was given in 61% of the retrospective group. The median heart rate for the prospective group was significantly lower (66 versus 77 beats/minute; p=0.0007). The composite cardiac complication rate was 2% in the prospective group versus 10% in the retrospective group (p=0.02). There were no deaths. On multivariate analysis, after adjusting for revised cardiac index score, there was a lower cardiac complication rate in the prospective group (odds ratio, 2.46; 95% CI, 1.3 to 4.5; p=0.003). In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity.

Long-Term Cardiac Outcome in High-Risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair

ObjectivesTo assess long-term outcome of patients at high cardiac risk undergoing endovascular or open AAA repair. MethodsPatients undergoing open or endovascular infrarenal AAA repair with ≥3 cardiac risk factors and preoperative cardiac stress testing (DSE) at 2 university hospitals were studied. Main outcome was cardiac event free and overall survival. Multivariate Cox regression analysis was used to evaluate the influence of type of AAA repair on long-term outcome. ResultsIn 124 patients (55 endovascular, 69 open) the number and type of cardiac risk factors, medication use and DSE results were similar in both groups. In multivariable analysis, adjusting for cardiac risk factors, stress test results, medication use, and propensity score endovascular repair was associated with improved cardiac event free survival (HR 0.54; 95% CI 0.30–0.98) but not with an overall survival benefit (HR 0.73; 95% CI 0.37–1.46). Importantly, statin therapy was associated with both improved overall survival (HR 0.42; 95% CI 0.21–0.83) and cardiac event free survival (HR 0.45; 95% CI 0.23–0.86). ConclusionsThe perioperative cardiac benefit of endovascular AAA repair in high cardiac risk patients is sustained during long-term follow-up provided patients are on optimal medical therapy but it is not associated with improved overall long-term survival.

The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial

Objective To evaluate the validity of preoperative cardiac stress testing using clinical predictors from the American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation before Noncardiac Surgery in patients undergoing vascular surgery. Design Prospective, randomized pilot study. Setting Academic medical center. Participants Patients undergoing elective abdominal aortic, infrainguinal, and carotid vascular surgery. Interventions After stratification by American College of Cardiology/American Heart Association (ACC/AHA) Guideline parameters, 99 patients were randomized to preoperative cardiac stress testing or to no stress testing and followed for up to 12 months postoperatively for adverse cardiac outcomes. Measurements and main results Before hospital discharge of 46 patients who underwent preoperative stress testing, 7 (15%) had inducible ischemia with no adverse postoperative cardiac outcomes, whereas only 1 (3%) of 39 patients (85%) with no ischemia had a nonfatal adverse cardiac outcome ( p = not significant). Of 53 patients without preoperative stress testing, only 2 (4%) had a nonfatal adverse postoperative cardiac outcome. There were no cardiac deaths. At 12-month follow-up in 79 (80%) patients, there was 1 nonfatal adverse cardiac outcome (no stress test) and 1 cardiac death (abnormal stress test), reflecting a 1% 12-month cardiac morbidity and mortality. Conclusion In this small prospective, randomized study evaluating the validity of preoperative cardiac stress testing using ACC/AHA Guidelines before major vascular surgery, preoperative cardiac stress testing offered no incremental value for determining postoperative adverse cardiac outcomes. Larger randomized clinical trials are needed to confirm these findings.