Patterns and Predictors of Stress Testing Modality After Percutaneous Coronary Stenting: Retrospective Analysis Using Data From the NCDR®

Study Questions:

What are the temporal trends and geographic variation in choice of stress testing modality after percutaneous coronary intervention (PCI), as well as associations between modality and procedure use after testing?


CathPCI Registry data were linked with identifiable Medicare claims to capture stress testing use between 60 and 365 days post-PCI, and procedures within 90 days after testing. Testing rates and modality used were modeled on the basis of patient, procedure, and PCI facility factors, calendar quarter, and Census Divisions using Poisson and logistic regression. Post-test procedure use was assessed using Gray’s test.


Among 284,971 patients, the overall stress testing rate after PCI was 53.1 per 100 person-years. Testing rates declined from 59.3 in quarter 1 (2006) to 47.1 in quarter 4 (2008), but the relative use of modalities changed little. Among exercise testing recipients, adjusted proportions receiving electrocardiography-only testing varied from 6.8% to 22.8% across Census Divisions; and among exercise testing recipients having an imaging test, the proportion receiving echocardiography (versus nuclear) varied from 9.4% to 34.1%. Post-test procedure use varied among modalities; exercise electrocardiography-only testing was associated with more subsequent stress testing (13.7% vs. 2.9%; p <0.001), but less catheterization (7.4% vs. 14.1%; p < 0.001) than imaging-based tests.


The authors concluded that there were modest reductions in stress testing after PCI occurring between 2006 and 2008, but this cannot be ascribed to trends in use of any single modality.


This study reports that between 2006 and 2008, stress testing utilization declined roughly equally across testing modalities. Geographic region was strongly associated with the modality patients Received, and notable differences occurred in the downstream procedure use associated with each modality. Overall, declining test utilization in the post-PCI population suggests that multipronged efforts at appropriateness are having a measurable effect. However, additional research is needed to ensure that unintended consequences do not result, such as limiting access for patients with legitimate testing needs. As efforts continue to identify the optimal use of stress testing after PCI while controlling cost, carefully designed, comprehensive evaluations will provide important insight.

Keywords: Electrocardiography, Percutaneous Coronary Intervention

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