title: Cardiac Stress Testing during Workup for Abdominal Aortic Aneurysm Repair Is Not Associated with Improved Patient Outcomes.
abstract: BACKGROUND
  Cardiac stress testing (CST) is commonly used to help determine whether patients with abdominal aortic aneurysms (AAAs) are better candidates for open versus endovascular repair, although it is unknown whether the use of CST achieves its goal of optimizing patient selection and postoperative outcomes.
  
  
  METHODS
  We retrospectively identified 3,635 patients in the Vascular Quality Initiative database (2010-2012) with an AAA ≥ 5.0 cm who were candidates for either open or endovascular AAA repair. The Vascular Study Group Cardiac Risk Index (VSG-CRI) was used to stratify patient risk. We applied generalized estimating equations with inverse probability weighting (IPW) to adjust for patient factors and hospital-level CST utilization to evaluate the effect of CST on composite of 30-day major adverse cardiac events or mortality (MACE-M) following AAA repair.
  
  
  RESULTS
  CST was utilized in 1,627 (45%) patients during AAA workup, including 451 of 794 (57%) patients selected for open repair and 1,176 of 2,841 (41%) selected for endovascular repair. After IPW, the use of CST was not associated with the probability of patients receiving open versus endovascular repair (OR: 1.00; 95% CI: 0.77-1.32). As compared to patients without CST during AAA workup, adjusted analyses revealed that CST utilization was not associated with improved MACE or mortality outcomes following AAA repair. Among patients receiving CST, an abnormal CST was not significantly associated with selection of open versus endovascular repair or with postoperative outcomes after adjustment for the VSG-CRI score. Similar results were found for patients with either low or high VSG-CRI scores.
  
  
  CONCLUSIONS
  Utilization of CST during workup for AAA is not associated with procedure selection and improved outcomes. Identifying risk factors for individuals who would benefit from preoperative CST before AAA repair will help reduce health care utilization and improve postoperative outcomes.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT. Electronic address: Benjamin.Brooke@hsc.utah.edu.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Sarfati
authors.affiliation: Division of Epidemiology, Department of Medicine, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Yingying
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Division of Epidemiology, Department of Medicine, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Yue
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Division of Epidemiology, Department of Medicine, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Angela P
authors.initials: AP
authors.lastname: Presson
authors.affiliation: Division of Epidemiology, Department of Medicine, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Tom H
authors.initials: TH
authors.lastname: Greene
authors.affiliation: Division of Vascular Surgery, Department of Surgery, University of Utah, School of Medicine, Salt Lake City, UT.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Kraiss
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D000066491:Clinical Decision-Making; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005080:Exercise Test; D005260:Female; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D019564:Unnecessary Procedures