Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients

Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.