Presurgery Stress Tests and Beta Blockers No Longer Considered Necessary

Routine perioperative stress testing provides no incremental diagnostic yield in patients at low risk for cardiac events, and indiscriminate perioperative therapy with beta-blockers can increase mortality in otherwise stable patients, claims a new report.

An article by physicians at the University of Michigan (U-M; Ann Arbor, USA) that critically evaluates costly preoperative practices was published following new guidelines released by the American College of Cardiology (ACC; Washington, DC, USA) and the American Heart Association (AHA; Dallas, TX, USA), which recommend that preoperative medications should be reserved for only high risk patients undergoing complicated surgeries.

The U-M physicians, however, went a step further by critically evaluating other costly preoperative practices, such stress testing and coronary revascularization therapies such as stenting and bypass surgery for patients with stable heart disease. The authors claim that perioperative tests and treatments improve outcomes only when targeted at specific patient subsets. For example, routine perioperative stress testing provides no incremental diagnostic yield in patients at low risk for cardiac events; in fact, the authors claim, stress tests do not reliably predict potentially fatal issues such as coronary artery clots and spasms. Indiscriminate perioperative therapy with beta-blockers, they add, can increase mortality in otherwise stable patients, if dosages are not carefully monitored over months. Thus, many accepted perioperative practices conflict with the evidence and can be safely discontinued while preserving outcomes and reducing costs. The report was published ahead of print on November 30, 2009, in the Annals of Internal Medicine.

"Traditionally we've thought of stress tests as the best way to figure out whether a patient is ready for surgery," said study coauthor Vineet Chopra, M.D., a clinical assistant professor of internal medicine at the U-M medical school. "It appears that many noninvasive stress tests are not only unnecessary, but potentially misleading. Occasionally such testing may lead to unnecessary invasive testing which has its own set of risks, or unnecessary medical treatment which also has some risks attached.”

Related Links:
University of Michigan
American College of Cardiology
American Heart Association