Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website http://www.cardiologyres.org

Original Article

Volume 10, Number 1, February 2019, pages 1-8

Preoperative Cardiac Stress Tests Ordered in the Preoperative Evaluation Clinic: A Retrospective Review of Ordering Patterns

Figure 1. Cardiac stress tests ordered exclusion flow diagram (flow diagram of the charts analyzed and excluded).

**Table 1.** Brigham and Women’s Hospital Preoperative Electrocardiogram Ordering Guidelines
Shown is the list of institutional specific guidelines at Brigham and Women’s Hospital for ordering preoperative electrocardiograms. These supplement the American College of Cardiology/American Heart Association Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. AICD: automatic implantable cardioverter-defibrillator; RCRI: revised cardiac risk index.
Any patient over the age of 65 (updated in June 2015, previously age 50)
Any patient with a known arrhythmia
Any patient with a suspected arrhythmia by history regardless of age
Any patient with an AICD or pacemaker regardless of age
Any patient with known significant cardiac history regardless of RCRI or age

Table 1. Brigham and Women’s Hospital Preoperative Electrocardiogram Ordering Guidelines

Shown is the list of institutional specific guidelines at Brigham and Women’s Hospital for ordering preoperative electrocardiograms. These supplement the American College of Cardiology/American Heart Association Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. AICD: automatic implantable cardioverter-defibrillator; RCRI: revised cardiac risk index.

Any patient over the age of 65 (updated in June 2015, previously age 50)

Any patient with a known arrhythmia

Any patient with a suspected arrhythmia by history regardless of age

Any patient with an AICD or pacemaker regardless of age

Any patient with known significant cardiac history regardless of RCRI or age

**Table 2.** Cardiac Stress Test Ordered by Indication
Cardiac stress ordered by indication	Number	Percent of total
Breakdown of indications for order of cardiac stress tests ordered. “Percent of total” column represents the percent of cardiac stress tests in that category (row) of all cardiac stress tests ordered. ECG: electrocardiogram.
Societal guidelines	153	43% (153/355)
Societal guidelines: ECG	101	28% (101/355)
Societal guidelines: algorithm	52	15% (52/355)
Institutional guidelines	104	29% (104/355)
Other	98	28% (98/355)
Charts analyzed	355	100% (355/355)

Table 2. Cardiac Stress Test Ordered by Indication

Cardiac stress ordered by indication

Number

Percent of total

Breakdown of indications for order of cardiac stress tests ordered. “Percent of total” column represents the percent of cardiac stress tests in that category (row) of all cardiac stress tests ordered. ECG: electrocardiogram.

Societal guidelines

153

43% (153/355)

Societal guidelines: ECG

101

28% (101/355)

Societal guidelines: algorithm

15% (52/355)

Institutional guidelines

104

29% (104/355)

Other

28% (98/355)

Charts analyzed

355

100% (355/355)

**Table 3.** Breakdown of Cardiac Stress Test Categorized as “Other”
Cardiac stress tests categorized as “Other”	Number	Percent of “Other” cardiac stress tests	Number peer review agreed	Percent peer review agreed
Breakdown of cardiac stress tests categorized as “Other”. “Percent of “Other” cardiac stress Tests” column represents the percent of cardiac stress tests in that category (row) of cardiac stress tests categorized as “Other”. “Number peer review agreed” column represents the number of cardiac stress tests of that type of indication for order (row) that by peer review was agreed upon as appropriate. “Percent peer review agreed” column represents the percent of cardiac stress tests of that type of indication for order (row) that by peer review was agreed upon as appropriate. METS: metabolic equivalents; echo: echocardiogram; bpm: beats per minute.
History of chest pain	64	64% (64/98)	38	60% (38/64)
Low METS (< 4), but did not meet societal guidelines	14	14% (14/98)	4	29% (4/14)
History of abnormal stress test	5	5% (5/98)	4	80% (4/5)
Clinical history warranted electrocardiogram which required further investigation with cardiac stress test	3	3% (3/98)	3	100% (3/3)
History of aortic stenosis and coronary artery disease	2	2% (2/98)	0	0% (0/2)
History of significant coronary artery disease	2	2% (2/98)	0	0% (0/2)
History of intraoperative ST changes	2	2% (2/98)	1	50% (1/2)
History of low ejection fraction echocardiogram	1	1% (1/98)	1	100% (1/1)
History of pre-syncope	1	1% (1/98)	0	0% (0/1)
History of postoperative ST changes	1	1% (1/98)	0	0% (0/1)
History of stress echo and beta blocker for unknown reason (but unable to obtain stress echo report)	1	1% (1/98)	0	0% (0/1)
Increasing dyspnea (but METS ≥ 4)	1	1% (1/98)	1	100% (1/1)
Status post cardiac transplant	1	1% (1/98)	0	0% (0/1)
Sinus bradycardia (heart rate 40 bpm)	1	1% (1/98)	0	0% (0/1)
Total	98	100% (98/98)	52	53% (52/98)

Table 3. Breakdown of Cardiac Stress Test Categorized as “Other”

Cardiac stress tests categorized as “Other”

Number

Percent of “Other” cardiac stress tests

Number peer review agreed

Percent peer review agreed

Breakdown of cardiac stress tests categorized as “Other”. “Percent of “Other” cardiac stress Tests” column represents the percent of cardiac stress tests in that category (row) of cardiac stress tests categorized as “Other”. “Number peer review agreed” column represents the number of cardiac stress tests of that type of indication for order (row) that by peer review was agreed upon as appropriate. “Percent peer review agreed” column represents the percent of cardiac stress tests of that type of indication for order (row) that by peer review was agreed upon as appropriate. METS: metabolic equivalents; echo: echocardiogram; bpm: beats per minute.

History of chest pain

64% (64/98)

60% (38/64)

Low METS (< 4), but did not meet societal guidelines

14% (14/98)

29% (4/14)

History of abnormal stress test

5% (5/98)

80% (4/5)

Clinical history warranted electrocardiogram which required further investigation with cardiac stress test

3% (3/98)

100% (3/3)

History of aortic stenosis and coronary artery disease

2% (2/98)

0% (0/2)

History of significant coronary artery disease

2% (2/98)

0% (0/2)

History of intraoperative ST changes

2% (2/98)

50% (1/2)

History of low ejection fraction echocardiogram

1% (1/98)

100% (1/1)

History of pre-syncope

1% (1/98)

0% (0/1)

History of postoperative ST changes

1% (1/98)

0% (0/1)

History of stress echo and beta blocker for unknown reason (but unable to obtain stress echo report)

1% (1/98)

0% (0/1)

Increasing dyspnea (but METS ≥ 4)

1% (1/98)

100% (1/1)

Status post cardiac transplant

1% (1/98)

0% (0/1)

Sinus bradycardia (heart rate 40 bpm)

1% (1/98)

0% (0/1)

Total

100% (98/98)

53% (52/98)

**Table 4.** Assessment of Ordering Different Types of Cardiac Stress Tests
	Number	Percentage of proper ordering
Shown is the analysis of the ordering of different types of cardiac stress tests, specifically pharmacological vasodilator cardiac stress tests and exercise ECG stress tests. LBBB: left bundle branch block; RV: right ventricle; ECG: electrocardiogram.
Patients with LBBB or RV pacing with any type of stress test ordered	51	41% (21/51)
Patients with LBBB or RV pacing with pharmacological vasodilator stress test ordered	21
Exercise ECG stress tests ordered	64	58% (37/64)
Exercise ECG stress tests ordered with normal resting baseline ECG	37

Table 4. Assessment of Ordering Different Types of Cardiac Stress Tests

Number

Percentage of proper ordering

Shown is the analysis of the ordering of different types of cardiac stress tests, specifically pharmacological vasodilator cardiac stress tests and exercise ECG stress tests. LBBB: left bundle branch block; RV: right ventricle; ECG: electrocardiogram.

Patients with LBBB or RV pacing with any type of stress test ordered

41% (21/51)

Patients with LBBB or RV pacing with pharmacological vasodilator stress test ordered

Exercise ECG stress tests ordered

58% (37/64)

Exercise ECG stress tests ordered with normal resting baseline ECG