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Stress test performed in more than half of patients within 2 years of revascularization
Shah B. J Am Coll Cardiol. 2010;56:1328-1334.
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Nearly 60% of all patients in community practice who underwent revascularization had at least one cardiac stress test within 24 months of the procedure, new study data suggested.
“Although the routine use of stress testing within 2 years of revascularization is considered inappropriate by recent American College of Cardiology Foundation appropriate use criteria (ACCF AUC), […] more than 50% of patients of a large national insurance provider had at least one stress test between 90 days and 2 years after coronary revascularization in community practice,” the researchers wrote.
Their study included patients between the ages of 18 and 64 years who underwent revascularization. All patients were taken from UnitedHealthcare’s claims database from July 1, 2004 to June 30, 2007.
Of the total study population (n=28,177), percutaneous coronary intervention was performed in 21,046 cases and CABG in 7,131 cases. Fifty-nine percent had at least one cardiac stress test within 24 months, with 61% in the PCI arm and 51% in the CABG arm.
According to researchers, the incidence of testing was found to increase at both 6 months and 12 months after revascularization, suggesting an association with elective follow-up office visits. There was also notable stress test incidence variability in geographic locations with at least 300 revascularizations, ranging from 52% (Columbus, Ohio) to 71% (Phoenix).
“Our findings provide a perspective on the real-world patterns of stress testing after revascularization and, more importantly, on the geographic variability and yield of post-revascularization stress imaging in community practice,” the researchers concluded. “Further studies are warranted to investigate specific drivers for stress testing and the possible role of ACCF AUC in guiding clinical decision-making.” – by Brian Ellis
This article examines data collected before and soon after appropriate use criteria (AUC) for single-photon emission CT myocardial perfusion imaging were published, indicating that imaging routinely soon after revascularization in asymptomatic patients is inappropriate. This analysis does not include, therefore, data exclusive to the period of decline in procedure growth in nuclear cardiology (ie, 2006 and beyond). Much of this imaging was driven by local community practice standards and fear of liability in this high-risk population. The AUC actually freed up physicians to follow stricter guidelines. Now that SPECT AUC have been promulgated, it would be important to reassess this data to determine if the restriction of stress testing has improved outcomes or caused some patients with ischemia post-revascularization to be undertreated.
Also, it should be noted that the 5% rate of revascularization is somewhat misleading in terms of the value of the noninvasive tests. Many symptomatic patients were very likely spared invasive evaluation, saving vascular risks, contrast material, time off of work and health care dollars by having a negative or low-risk stress nuclear myocardial perfusion scan.
– Kim Allan Williams, MD
Cardiology Today Editorial Board member
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