Physicians should "throttle back" from routinely ordering stress tests and prescribing beta blockers to patients before non-cardiac surgeries, according to a report by the University of Michigan recently released online.
Studies suggest such pre-operative tests and medications do not save lives and patients can skip them without suffering complications later, the U-M physicians write in a special report released ahead of print in Annals of Internal Medicine.
The article by U-M physicians appears as the American College of Cardiology and American Heart Association release new guidelines showing pre-operative medications should be reserved for only high risk patients undergoing complicated surgeries.
But U-M physicians go a step further by critically evaluating other costly pre-operative practices -- stress testing and coronary revascularizations such as stenting and bypass surgery for patients with stable heart disease.
These patients do not benefit from revascularization as studies show that it may trigger as many events as it prevents.
"Physicians may struggle with implementing these evidence-based guidelines for a variety of reasons, including legal concerns regarding pre-operative cardiac events, pressure from surgical colleagues and reliance on testing and procedures for income," says senior author Kim Eagle, M.D., director of the U-M Cardiovascular Center and the Albion Walter Hewlett Professor of Internal Medicine.
"It's imperative that any form of health care reform provide incentives to follow these guidelines," Eagle says. "It is the quality of care, not the quantity of tests, that matters most."
Eagle and his U-M colleagues describe screening patients with stable cardiac disease before non-cardiac surgeries such as hip replacement and gallbladder surgery as a failed strategy.
Stress tests do not reliably predict potentially fatal issues such as coronary artery clots and spasms, and beta blockers can harm patients whose heart disease is stable if dosages are not carefully monitored over months. Most patients are given the new medications in the days and weeks before surgery and before they can have a significant impact on relieving stress on the heart.
"Traditionally we've thought of stress tests as the best way to figure out whether a patient is ready for surgery," says Vineet I. Chopra, M.D., a hospitalist at UMHS and 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," Chopra says. "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," he says.
The new ACC/AHA guidelines on beta blockers advise doctors to identify the correct patients for medical therapy, rather than use a one-size fits all approach. Broad recommendations to treat all diabetics and those with high blood pressure with the medications before surgery are no longer the case, Chopra says.
- Vineet Chopra, M.D., Scott A. Flanders, M.D., James B. Froehlich, M.D., MPH; Wei C. Lau, M.D., and Kim A. Eagle. Perioperative Practice: Time to Throttle Back. Annals of Internal Medicine, December 1, 2009
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