Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery

Published:October 19, 2022DOI:
      Adverse cardiac events after laparoscopic bariatric surgery are rare, yet preoperative cardiology evaluation and testing remain common, resulting in the overuse of cardiac testing in low-risk patients. Our objective was to assess the frequency of, and factors associated with, overuse of preoperative cardiac testing in patients at low cardiac risk before laparoscopic bariatric surgery. We retrospectively reviewed data from 1,094 adult patients who underwent laparoscopic bariatric surgery at our institution from January 1, 2015, through December 31, 2019. The cardiac risk was determined using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk model. Multivariate logistic regression was used to evaluate risk factors associated with the overuse of cardiac testing in low-risk patients. Overall, 1,059 patients (96.8%) were estimated to be at low cardiac risk by the RCRI, and 1,094 (100%) were at low cardiac risk by NSQIP MICA. A total of 587 patients (51.8%) were referred to cardiology for preoperative evaluation, and 643 patients (56.7%) underwent one or more preoperative cardiac tests. Factors associated with overuse of preoperative cardiac testing in low-risk patients included preoperative cardiology referral (adjusted odds ratio 37.2, 95% confidence interval 25.3 to 54.7) and patient age (adjusted odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Overuse of preoperative cardiac testing was common in patients at low cardiac risk before laparoscopic bariatric surgery. Preoperative referral to cardiology was the most significant risk factor associated with the overuse of preoperative cardiac testing. Application of risk models such as the RCRI or NSQIP MICA at the time of bariatric program enrollment may reduce unnecessary preoperative cardiac testing in low-risk patients.
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        • Ward ZJ
        • Bleich SN
        • Cradock AL
        • Barrett JL
        • Giles CM
        • Flax C
        • Long MW
        • Gortmaker SL.
        Projected U.S. State-Level prevalence of adult obesity and severe obesity.
        N Engl J Med. 2019; 381: 2440-2450
        • Campos GM
        • Khoraki J
        • Browning MG
        • Pessoa BM
        • Mazzini GS
        • Wolfe L.
        Changes in utilization of bariatric surgery in the United States from 1993 to 2016.
        Ann Surg. 2020; 271: 201-209
        • Höskuldsdóttir G
        • Sattar N
        • Miftaraj M
        • Näslund I
        • Ottosson J
        • Franzén S
        • Svensson AM
        • Eliasson B.
        Potential effects of bariatric surgery on the incidence of heart failure and atrial fibrillation in patients with type 2 diabetes mellitus and obesity and on mortality in patients with preexisting heart failure: a nationwide, matched, observational cohort study.
        J Am Heart Assoc. 2021; 10e019323
        • Doumouras AG
        • Wong JA
        • Paterson JM
        • Lee Y
        • Sivapathasundaram B
        • Tarride JE
        • Thabane L
        • Hong D
        • Yusuf S
        • Anvari M.
        Bariatric surgery and cardiovascular outcomes in patients with obesity and cardiovascular disease: a population-based retrospective cohort study.
        Circulation. 2021; 143: 1468-1480
        • Singh P
        • Subramanian A
        • Adderley N
        • Gokhale K
        • Singhal R
        • Bellary S
        • Nirantharakumar K
        • Tahrani AA.
        Impact of bariatric surgery on cardiovascular outcomes and mortality: a population-based cohort study.
        Br J Surg. 2020; 107: 432-442
        • Wiggins T
        • Guidozzi N
        • Welbourn R
        • Ahmed AR
        • Markar SR.
        Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: a systematic review and meta-analysis.
        PLoS Med. 2020; 17e1003206
        • Ruzieh M
        • Rogers AM
        • Banerjee K
        • Soleymani T
        • Zhan X
        • Foy AJ
        • Peterson BR.
        Safety of bariatric surgery in patients with coronary artery disease.
        Surg Obes Relat Dis. 2020; 16: 2031-2037
        • Fleisher LA
        • Fleischmann KE
        • Auerbach AD
        • Barnason SA
        • Beckman JA
        • Bozkurt B
        • Davila-Roman VG
        • Gerhard-Herman MD
        • Holly TA
        • Kane GC
        • Marine JE
        • Nelson MT
        • Spencer CC
        • Thompson A
        • Ting HH
        • Uretsky BF
        • Wijeysundera DN
        American College of Cardiology, American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 64: e77-137
        • Love KM
        • Mehaffey JH
        • Safavian D
        • Schirmer B
        • Malin SK
        • Hallowell PT
        • Kirby JL.
        Bariatric surgery insurance requirements independently predict surgery dropout.
        Surg Obes Relat Dis. 2017; 13: 871-876
        • Lee TH
        • Marcantonio ER
        • Mangione CM
        • Thomas EJ
        • Polanczyk CA
        • Cook EF
        • Sugarbaker DJ
        • Donaldson MC
        • Poss R
        • Ho KK
        • Ludwig LE
        • Pedan A
        • Goldman L.
        Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
        Circulation. 1999; 100: 1043-1049
        • Gupta PK
        • Gupta H
        • Sundaram A
        • Kaushik M
        • Fang X
        • Miller WJ
        • Esterbrooks DJ
        • Hunter CB
        • Pipinos II
        • Johanning JM
        • Lynch TG
        • Forse RA
        • Mohiuddin SM
        • Mooss AN.
        Development and validation of a risk calculator for prediction of cardiac risk after surgery.
        Circulation. 2011; 124: 381-387
        • Kerr EA
        • Chen J
        • Sussman JB
        • Klamerus ML
        • Nallamothu BK.
        Stress testing before low-risk surgery: so many recommendations, so little overuse.
        JAMA Intern Med. 2015; 175: 645-647
        • Peterson B
        • Ghahramani M
        • Emerich M
        • Foy AJ.
        Frequency of appropriate and low-risk noncardiac preoperative stress testing across medical specialties.
        Am J Cardiol. 2018; 122: 744-748
        • Rubin DS
        • Hughey R
        • Gerlach RM
        • Ham SA
        • Ward RP
        • Nagele P.
        Frequency and outcomes of preoperative stress testing in total hip and knee arthroplasty from 2004 to 2017.
        JAMA Cardiol. 2021; 6: 13-20
      1. Choosing Wisely. Heart stress tests before surgery. Available at: Accessed on June 25, 2022.

      2. American Heart Association. Strategies to reduce low-value cardiovascular care: a scientific statement from the American Heart Association. Available at: Accessed on June 25, 2022.