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

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.b5526 (Published 28 January 2010) Cite this as: BMJ 2010;340:b5526
  1. Duminda N Wijeysundera, lecturer123,
  2. W Scott Beattie, R Fraser Elliot chair in cardiac anaesthesia2,
  3. Peter C Austin, senior scientist134,
  4. Janet E Hux, senior scientist135,
  5. Andreas Laupacis, scientist 1367
  1. 1Institute for Clinical Evaluative Sciences, Toronto, Ontario M4N 3M5, Canada
  2. 2Department of Anesthesia, Toronto General Hospital and University of Toronto, Toronto, Ontario M5G 2C4
  3. 3Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario M5T 3M6
  4. 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7
  5. 5Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario M4N 3M5
  6. 6Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario M5B 1W8
  7. 7Department of Medicine, St Michael’s Hospital and University of Toronto, Toronto, Ontario M5B 1W8
  1. Correspondence to: D N Wijeysundera d.wijeysundera{at}utoronto.ca
  • Accepted 22 October 2009

Abstract

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 hospitals in Ontario, Canada, between 1 April 1994 and 31 March 2004.

Participants Patients aged 40 years or older who underwent specific elective intermediate to high risk non-cardiac surgical procedures.

Interventions Non-invasive cardiac stress testing performed within six months before surgery.

Main outcome measures Postoperative one year survival and length of stay in hospital.

Results Of the 271 082 patients in the entire cohort, 23 991 (8.9%) underwent stress testing. After propensity score methods were used to reduce important differences between patients who did or did not undergo preoperative stress testing and assemble a matched cohort (n=46 120), testing was associated with improved one year survival (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.99; P=0.03) and reduced mean hospital stay (difference −0.24 days, 95% CI −0.07 to −0.43; P<0.001). In an analysis of subgroups defined by Revised Cardiac Risk Index (RCRI) class, testing was associated with harm in low risk patients (RCRI 0 points: HR 1.35, 95% CI 1.05 to 1.74), but with benefit in patients who were at intermediate risk (RCRI 1-2 points: 0.92, 95% CI 0.85 to 0.99) or high risk (RCRI 3-6 points: 0.80, 95% CI 0.67 to 0.97).

Conclusions Preoperative non-invasive cardiac stress testing is associated with improved one year survival and length of hospital stay in patients undergoing elective intermediate to high risk non-cardiac surgery. These benefits principally apply to patients with risk factors for perioperative cardiac complications.

Footnotes

  • Funding: DNW is supported by a Clinician-Scientist Award from the Canadian Institutes of Health Research and a Merit Award from the Department of Anesthesia at the University of Toronto. WSB is the R Fraser Elliot Chair of Cardiac Anesthesia at the University Health Network. PCA is supported by a Career Investigator Award from the Heart and Stroke Foundation of Ontario. This study was supported in part by the Institute for Clinical Evaluative Sciences, which is itself supported in part by the Ontario Ministry of Health and Long-Term Care. The study sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The opinions, results, and conclusions are those of the authors, and no endorsement by the Ontario Ministry of Health and Long-Term Care or the Institute for Clinical Evaluative Sciences is intended or should be inferred.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

  • Ethical approval: Research ethics approval was obtained from Sunnybrook Health Sciences Centre.

  • Data sharing: No additional data available.

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