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Ponukumati AS, Columbo JA, Henkin S, Beach JM, Suckow BD, Goodney PP, Scali ST, Stone DH. Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events. Vasc Med 2024:1358863X241247537. [PMID: 38708691 DOI: 10.1177/1358863x241247537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines. METHODS We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE). RESULTS Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation. CONCLUSIONS Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.
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Affiliation(s)
- Aravind S Ponukumati
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jesse A Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Department of Surgery, Department of Veterans Affairs Medical Center, White River Junction, VT, USA
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Jocelyn M Beach
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Bjoern D Suckow
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Salvatore T Scali
- Division of Vascular Surgery, University of Florida, Gainesville, FL, USA
| | - David H Stone
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Columbo JA, Scali ST, Jacobs BN, Scully RE, Suckow BD, Huber TS, Neal D, Stone DH. Size thresholds for repair of abdominal aortic aneurysms warrant reconsideration. J Vasc Surg 2024; 79:1069-1078.e8. [PMID: 38262565 PMCID: PMC11032259 DOI: 10.1016/j.jvs.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND The historical size threshold for abdominal aortic aneurysm (AAA) repair is widely accepted to be 5.5 cm for men and 5.0 cm for women. However, contemporary AAA rupture risks may be lower than historical benchmarks, which has implications for when AAAs should be repaired. Our objective was to use contemporary AAA rupture rates to inform optimal size thresholds for AAA repair. METHODS We used a Markov chain analysis to estimate life expectancy for patients with AAA. The primary outcome was AAA-related mortality. We estimated survival using Social Security Administration life tables and published contemporary AAA rupture estimates. For those undergoing repair, we modified survival estimates using data from the Vascular Quality Initiative and Medicare on complications, late rupture, and open conversion. We used this model to estimate the AAA repair size threshold that minimizes AAA-related mortality for 60-year-old average-health men and women. We performed a sensitivity analysis of poor-health patients and 70- and 80-year-old base cases. RESULTS The annual risk of all-cause mortality under surveillance for a 60-year-old woman presenting with a 5.0 cm AAA using repair thresholds of 5.5 cm, 6.0 cm, 6.5 cm, and 7.0 cm was 1.7%, 2.3%, 2.7%, and 2.8%, respectively. The corresponding risk for a man was 2.3%, 2.9%, 3.3%, and 3.4% for the same repair thresholds, respectively. For a 60-year-old average-health woman, an AAA repair size of 6.1 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 5.7 cm to 7.1 cm. For a 60-year-old average-health man, an AAA repair size of 6.9 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 6.0 cm to 7.4 cm. Women in poor health, at various age strata, had optimal AAA repair size thresholds that were >6.5 cm, whereas men in poor health, at all ages, had optimal repair size thresholds that were >8.0 cm. CONCLUSIONS The optimal threshold for AAA repair is more nuanced than a discrete size. Specifically, there appears to be a range of AAA sizes for which repair is reasonable to minmized AAA-related mortality. Notably, they all are greater than current guideline recommendations. These findings would suggest that contemporary AAA size thresholds for repair should be reconsidered.
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Affiliation(s)
- Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT.
| | - Salvatore T Scali
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Benjamin N Jacobs
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Rebecca E Scully
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
| | - Bjoern D Suckow
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
| | - Thomas S Huber
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Dan Neal
- University of Florida School of Medicine, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - David H Stone
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
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