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Original research article
Facility-level association of preoperative stress testing and postoperative adverse cardiac events
  1. Javier A Valle1,2,
  2. Laura Graham3,
  3. Thejasvi Thiruvoipati4,
  4. Gary Grunwald1,2,
  5. Ehrin J Armstrong1,2,
  6. Thomas M Maddox5,
  7. Mary T Hawn6,
  8. Steven M Bradley7
  1. 1 Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, USA
  2. 2 Division of Cardiovascular Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
  3. 3 Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
  4. 4 Division of Cardiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
  5. 5 Department of Cardiovascular Medicine, Washington University School of Medicine, St Louis, Missouri, USA
  6. 6 Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
  7. 7 Minneapolis Heart Institute, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Javier A Valle, Veterans Affairs Eastern Colorado Health Care System, University of Colorado School of Medicine, Division of Cardiology, Denver, CO 80220, USA; javier.valle{at}


Background Despite limited indications, preoperative stress testing is often used prior to non-cardiac surgery. Patient-level analyses of stress testing and outcomes are limited by case mix and selection bias. Therefore, we sought to describe facility-level rates of preoperative stress testing for non-cardiac surgery, and to determine the association between facility-level preoperative stress testing and postoperative major adverse cardiac events (MACE).

Methods We identified patients undergoing non-cardiac surgery within 2 years of percutaneous coronary intervention in the Veterans Affairs (VA) Health Care System, from 2004 to 2011, facility-level rates of preoperative stress testing and postoperative MACE (death, myocardial infarction (MI) or revascularisation within 30 days). We determined risk-standardised facility-level rates of stress testing and postoperative MACE, and the relationship between facility-level preoperative stress testing and postoperative MACE.

Results Among 29 937 patients undergoing non-cardiac surgery at 131 VA facilities, the median facility rate of preoperative stress testing was 13.2% (IQR 9.7%–15.9%; range 6.0%–21.5%), and 30-day postoperative MACE was 4.0% (IQR 2.4%–5.4%). After risk standardisation, the median facility-level rate of stress testing was 12.7% (IQR 8.4%–17.4%) and postoperative MACE was 3.8% (IQR 2.3%–5.6%). There was no correlation between risk-standardised stress testing and composite MACE at the facility level (r=0.022, p=0.81), or with individual outcomes of death, MI or revascularisation.

Conclusions In a national cohort of veterans undergoing non-cardiac surgery, we observed substantial variation in facility-level rates of preoperative stress testing. Facilities with higher rates of preoperative stress testing were not associated with better postoperative outcomes. These findings suggest an opportunity to reduce variation in preoperative stress testing without sacrificing patient outcomes

  • perioperative management
  • stress testing
  • non-cardiac surgery
  • quality and outcomes

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  • Contributors All authors listed have contributed as warranted to merit authorship for this manuscript—from study design, data collection, analysis, interpretation and to manuscript review.

  • Funding Works further supported by NIH/NCATS Colorado CTSA (Grant No UL1 TR001082).

  • Disclaimer Contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

  • Competing interests JAV was supported by an NIH T32 training grant (HL0782) at the University of Colorado, Aurora, CO, while work was completed.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.