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Ellenbogen MI, Drmanovic A, Segal JB, Kapoor S, Wagner PC. Patient, provider, and system-level factors associated with preoperative cardiac testing: A systematic review. J Hosp Med 2023; 18:1021-1033. [PMID: 37728150 PMCID: PMC10877614 DOI: 10.1002/jhm.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Overuse of preoperative cardiac testing contributes to high healthcare costs and delayed surgeries. A large body of research has evaluated factors associated with variation in preoperative cardiac testing. However, patient, provider, and system-level factors associated with variation in testing have not been systematically studied. OBJECTIVE To conduct a systematic review to better delineate the patient, provider, and system-level factors associated with variation in preoperative cardiac testing. METHODS We included studies of an adult US population evaluating a patient, provider, or system-level factor associated with variation in preoperative cardiac testing for noncardiac surgery since 2012. Our search strategy used terms related to preoperative testing, diagnostic cardiac tests, and care variation with Ovid MEDLINE and Embase from inception through January 2023. We extracted study characteristics and factors associated with variation and qualitatively analyzed them. We assessed risk of bias using the Newcastle-Ottawa Scale and Evidence Project Risk of Bias tool. RESULTS Twenty-eight articles met inclusion criteria. Older age and higher comorbidity were strongly associated with higher-intensity testing. The evidence for provider and system-level covariates was weaker. However, there was strong evidence that a focus on primary care and away from preoperative clinic and cardiac consultations was associated with less testing and that interventions to reduce low-value testing can be successful. CONCLUSIONS There is significant interprovider and interhospital variation in preoperative cardiac testing, the correlates of which are not well-defined. Further work should aim to better understand these factors.
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Affiliation(s)
| | - Aleksandra Drmanovic
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Carey School of Business, 100 International Drive, Baltimore, MD, 21202, USA
| | - Jodi B. Segal
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Shrey Kapoor
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
- Johns Hopkins Carey School of Business, 100 International Drive, Baltimore, MD, 21202, USA
| | - Phillip C. Wagner
- Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA
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Gashler KR, Ritchie AK, Hood R, Ibekwe SO. Anesthetic Management of Renal Cell Carcinoma With Level 3 Inferior Vena Cava Extension in a Patient With Severe Coronary Artery Disease. Cureus 2023; 15:e44180. [PMID: 37641726 PMCID: PMC10460294 DOI: 10.7759/cureus.44180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 08/31/2023] Open
Abstract
A 49-year-old male with untreated type 2 diabetes and a family history of coronary artery disease (CAD) presented with right flank pain and profound progressive dyspnea on exertion to the emergency department of Ben Taub Hospital, a tertiary county hospital. Workup revealed right renal cell carcinoma with metastatic extension into the inferior vena cava (IVC). In addition, the patient had significant CAD with 95% occlusion of the proximal left anterior descending coronary artery amenable to percutaneous coronary intervention (PCI). After multidisciplinary discussions involving cardiovascular anesthesiology, cardiology, urology, and cardiothoracic surgery, it was estimated that the mortality benefit of immediate tumor resection outweighed the patient's need for PCI and further cardiac optimization. The patient underwent curative resection and thrombectomy under transesophageal echocardiography (TEE) guidance without complication, made an expedient recovery, and was discharged home on postoperative day seven.
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Affiliation(s)
- Kyle R Gashler
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Alan K Ritchie
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Ryan Hood
- Anesthesiology, Baylor College of Medicine, Houston, USA
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Belardi JA, Albertal M. Non-cardiac surgery after PCI: Watch out for complex lesions. Catheter Cardiovasc Interv 2017; 89:627-628. [PMID: 28342258 DOI: 10.1002/ccd.27008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/15/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Jorge A Belardi
- Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Mariano Albertal
- Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Schulman-Marcus J, Pashun RA, Feldman DN, Swaminathan RV. Coronary Angiography and Revascularization Prior to Noncardiac Surgery. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:3. [PMID: 26728404 DOI: 10.1007/s11936-015-0427-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The role of coronary angiography and revascularization, including percutaneous coronary intervention (PCI) prior to noncardiac surgery remains poorly defined. The goal of preoperative angiography and PCI is improved risk stratification and ideally risk reduction of postoperative cardiovascular events, such as myocardial infarction (MI). By current guidelines, these procedures should be performed sparingly in high-risk stable coronary artery disease (CAD) patients and routinely in patients with acute coronary syndrome (ACS). Anatomic assessment of CAD by routine invasive angiography is discouraged, although noninvasive assessment may soon be possible. As prior trials have failed to show a clear benefit in outcomes, PCI should only be considered in patients with high-risk anatomic features. The ideal management of other anatomic disease discovered by angiography is currently unknown. Limited registry data suggest that PCI is used more frequently than recommended, although the features of these procedures remain poorly elaborated. In patients who do undergo preoperative PCI, careful attention must be paid to patient-specific factors including the nature and urgency of surgery and duration of dual antiplatelet therapy. In summary, substantial evidence gaps warrant further research in this important area.
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Affiliation(s)
- Joshua Schulman-Marcus
- Departments of Medicine and Radiology, Weill Cornell Medical College, 1305 York Ave, 8th Avenue, New York, NY, 10021, USA.
| | - Raymond A Pashun
- Department of Medicine, New York Presbyterian Hospital, 505 E 70th St, Suite 450, New York, NY, 10021, USA.
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
| | - Rajesh V Swaminathan
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
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Garcia S, McFalls EO. Need for elective PCI prior to noncardiac surgery: high risk through the eyes of the beholder. J Am Heart Assoc 2014; 3:e001068. [PMID: 24970270 PMCID: PMC4309109 DOI: 10.1161/jaha.114.001068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 06/04/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Santiago Garcia
- University of Minnesota and Minneapolis VA Healthcare System, Minneapolis, MN (S.G., E.O.M.F.)
| | - Edward O. McFalls
- University of Minnesota and Minneapolis VA Healthcare System, Minneapolis, MN (S.G., E.O.M.F.)
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