Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System

Abstract

IMPORTANCEUp to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing. OBJECTIVE To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients. DESIGN, SETTING, AND PARTICIPANTS This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020. MAIN OUTCOMES AND MEASURESThe main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models). RESULTSA total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916(24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant sitelevel variation in stress testing. CONCLUSIONS AND RELEVANCEResults of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.

Routine Stress Testing After PCI in Patients With and Without Acute Coronary Syndrome

“…Prior clinical studies evaluating patients with ACS undergoing PCI have been conducted almost entirely in observational studies or small clinical trials. 4,5,[9][10][11] Moreover, to our knowledge, no randomized clinical trials to date have been powered to explore whether there is a relationship between the follow-up surveillance strategy and clinical outcomes specifically among patients with ACS undergoing PCI. Therefore, the current study may provide important insights into such unaddressed issues.…”

“…Cardiac stress testing has been widely implemented as an important part of the follow-up surveillance strategy after myocardial revascularization, including either PCI or coronary artery bypass grafting. [3][4][5] Nevertheless, it remains unclear Primary composite outcome A 0 to 1 y: HR, 0.52; 95% CI, 0.23-1.14; P = .10 1 to 2 y: HR, 1.91; 95% CI, 0.56-6.52; P = .30 0 to 1 y: HR, 0.78; 95% CI, 0.13-4.95; P = .80 1 to 2 y: HR, 0.22; 95% CI, 0.01-6.86; P = .39 0 to 1 y: HR, 0.36; 95% CI, 0.10-1.36; P = .13 1 to 2 y: HR, 2.76; 95% CI, 0.54-14.20; P = .22 0 to 1 y: HR, 0.55; 95% CI, 0.16-1.81; P = . whether this type of active surveillance strategy can improve clinical outcomes.…”

“…The findings of this analysis address a clinically important gap in the evidence base necessary to guide decisions about the follow-up strategy of patients with ACS undergoing PCI. Prior clinical studies evaluating patients with ACS undergoing PCI have been conducted almost entirely in observational studies or small clinical trials . Moreover, to our knowledge, no randomized clinical trials to date have been powered to explore whether there is a relationship between the follow-up surveillance strategy and clinical outcomes specifically among patients with ACS undergoing PCI.…”

“…Cardiac stress testing has been widely implemented as an important part of the follow-up surveillance strategy after myocardial revascularization, including either PCI or coronary artery bypass grafting . Nevertheless, it remains unclear whether this type of active surveillance strategy can improve clinical outcomes.…”

“…Furthermore, the appropriate follow-up surveillance strategy for patients with ACS who have undergone PCI remains debated, and theoretical arguments have been made to support an active surveillance follow-up strategy to reduce the risk of future ischemic events. 3 In real-world clinical practice, routine surveillance stress testing has commonly been implemented as part of post-PCI management, [3][4][5] but its prognostic value is still uncertain in high-risk patients presenting with ACS who have undergone PCI.…”