Stress Testing Before Abdominal Aortic Aneurysm Repair
- Use of stress testing prior to elective abdominal aortic aneurysm (AAA) repair varied six- to seven-fold among North American centers.
- Compared with centers in the lowest quintile of stress testing use, centers in the highest quintile had a higher adjusted likelihood of MACE after both endovascular AAA repair, with adjusted OR, 1.78 (95% CI, 1.37-2.30), and open AAA repair, with adjusted OR, 1.99 (95% CI, 1.53-2.59).
How often are stress tests performed prior to elective abdominal aortic aneurysm (AAA) repair? And how do perioperative outcomes differ between centers with high and low usage of preoperative stress testing?
This retrospective cohort study included patients in the Vascular Quality Initiative (VQI) registry who underwent elective endovascular AAA repair (EVAR) or open AAA repair (OAR) in North America from 2003–2019. The Vascular Study Group of New England cardiac risk index (VSG-CRI) was calculated for each patient. The primary exposure of interest was use of preoperative stress testing. Stress tests were characterized as negative or positive for ischemia, scar, or scar with peri-infarct ischemia. The primary outcome of interest was in-hospital major adverse cardiovascular events (MACE), including myocardial infarction (symptoms with electrocardiographic changes or troponin elevation), in-hospital stroke, heart failure exacerbation, and death. Rates of MACE and 1-year mortality were compared between centers in the highest and lowest quintiles of stress test usage.
From 324 centers, 43,396 EVAR patients and 8,935 OAR patients were included. Mean age was 73.5 years in the EVAR group and 69.5 years in the OAR group. A history of coronary artery disease was present in 22.2% of the EVAR group and 20.5% of the OAR group. Across all centers, preoperative stress testing was performed in 39.8% of EVAR patients (median rate by center, 35.9%; range, 10.4% [5th percentile] to 73.6% [95th percentile]) and 59.1% of OAR patients (median rate, 57.9%; range, 13.7% [5th percentile] to 85.9% [95th percentile]). Stress tests were positive in 9.2% of EVAR patients (including 6.2% with ischemia) and 11.7% of OAR patients (including 7.9% with ischemia).
The unadjusted MACE rate was 1.8% for EVAR and 11.6% for OAR, with 1-year mortality 4.6% for EVAR and 6.6% for OAR. Patients who underwent OAR had lower VSG-CRI scores compared with EVAR patients, and patients who underwent preoperative stress testing had higher scores than those who did not. Mean VSG-CRI scores did not differ significantly between centers in the highest and lowest quintiles of stress testing. Compared with centers in the lowest quintile, centers in the highest quintile had a higher adjusted likelihood of MACE after both EVAR (adjusted odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30) and OAR (OR, 1.99; 95% CI, 1.53-2.59). Among EVAR patients, 1-year mortality was greater in the highest quintile (adjusted OR, 1.22; 95% CI, 1.05-1.42), while there was no significant difference in mortality between quintiles for OAR patients (OR, 0.89; 95% CI, 0.66-1.21).
Usage of preoperative stress testing prior to AAA repair varied widely among centers, despite similar patient risk scores. Centers with high testing use had higher adjusted MACE rates and similar to slightly higher adjusted 1-year mortality rates.
At face value, the findings of this study do not support a routine practice of stress testing prior to AAA repair, as patients who underwent stress testing had less favorable outcomes than those who were not tested. However, it is possible that centers in the highest testing quintile had patients with a greater burden of unmeasured comorbidities. Moreover, without knowledge of the ways in which stress test findings impacted clinical decision making, including the choice between EVAR and OAR, it is unclear if or how these findings should influence practice. Stress test type and time elapsed between stress testing and AAA repair were not reported. Prospective studies examining stress testing in the greater context of perioperative management and long-term risk reduction are needed.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine
Keywords: Aortic Aneurysm, Abdominal, Cardiac Surgical Procedures, Coronary Artery Disease, Diagnostic Imaging, Electrocardiography, Endovascular Procedures, Exercise Test, Geriatrics, Heart Failure, Myocardial Infarction, Perioperative Care, Risk Factors, Stroke, Elective Surgical Procedures, Troponin, Vascular Diseases
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