American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery

Background: Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment. Methods: We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998). Resource use (testing, revascularization, and costs) and outcomes (perioperative death and myocardial infarction) were examined. Patients with and without clinical markers of risk for perioperative cardiac complications were compared. Results: The use of preoperative stress testing (88% to 47%; P < .00001), cardiac catheterization (24% to 11%; P < .05), and coronary revascularization (25% to 2%; P < .00001) decreased between control and postguideline groups, respectively. These changes persisted in the late postguideline group. Mean preoperative evaluation costs also fell ($1087 versus $171; P < .0001). Outcomes of death (4% versus 3% versus 2%) and myocardial infarction (7% versus 3% versus 5%) were not significantly different between control, postguideline, and late postguideline groups, respectively. Stress test rates were similar for patients at low risk versus high risk in the historical control group (84% versus 91%; P = .29) but lower for patients at low risk after guideline implementation (31% versus 61%; P = .003). Conclusion: Implementation of the American College of Cardiology/American Heart Association cardiac risk assessment guidelines appropriately reduced resource use and costs in patients who underwent elective aortic surgery without affecting outcomes. This effect was sustained 2 years after guideline implementation.