Stress tests overused after revascularization

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More than half of patients who underwent cardiac revascularization received a stress test within the next two years, contrary to American College of Cardiology Foundation recommendations, a new study found.

The retrospective study used a national claims database to identify more than 28,000 revascularization patients (about 21,000 who had percutaneous coronary intervention [PCI] and 7,100 who had coronary artery bypass grafting [CABG]). Between 90 days and two years after the procedure, 59% of the patients had a stress test. A higher percentage of PCI patients were tested (61% vs. 51% of CABG recipients), and nuclear imaging was the predominant method. The rates of testing varied by geographic area, with up to a 50% difference in testing rates by region.

The researchers also identified a spike in testing rates at 6 and 12 months after the procedures, indicating that testing was associated with follow-up office visits. They found that relatively few of the tests led to additional procedures: only 10% of those tested went on to coronary angiography and less than half of those patients received repeat revascularization. The study was published in the Oct. 12 Journal of the American College of Cardiology.

The findings indicate that the diagnostic yield of these tests is very low, the study authors concluded. They noted that appropriate use criteria put out by the American College of Cardiology Foundation recommend against routine stress testing. The study was unable to assess how many of these tests were motivated by patients' reports of symptoms; however, other research has shown that only 18% of PCI patients report angina symptoms one year after surgery.

The patients included in the study were treated between July 2004 and June 2007, and physicians today are more aware of the criteria for testing, according to an editorial accompanying the study. Still, the results serve as a “wake-up call to cardiovascular specialists,” the editorialist said. Cardiologists should not only adhere to evidence for testing, but also educate patients and referring physicians about this issue, because the likely alternative is that payers will require more pre-authorizations of testing, the editorial concluded.