Patterns of Cardiac Stress Testing After Revascularization in Community Practice

OBJECTIVES: The purpose of this study was to determine the pattern of cardiac stress testing after coronary revascularization in community practice. BACKGROUND: The American College of Cardiology Foundation appropriate use criteria provide guidance for the use of cardiac stress imaging after coronary revascularization. However, little is known regarding the use of routine cardiac stress testing in coronary artery bypass grafting or percutaneous coronary intervention patients as well as their downstream use of invasive procedures after noninvasive testing in community practice. METHODS: Use and timing of stress testing more than 90 days after revascularization in patients 18 to 64 years of age were determined from a national health insurance claims database from July 1, 2004, through June 30, 2007. Subsequent rates of angiography and repeat revascularization after stress testing also were examined. RESULTS: Of 28,177 patients undergoing revascularization (21,046 percutaneous coronary intervention procedures and 7,131 coronary artery bypass grafting procedures), 59% had at least 1 cardiac stress test within 24 months. Sixty-one percent of patients with percutaneous coronary intervention and 51% of patients with coronary artery bypass grafting had undergone testing by 24 months. Nuclear imaging was the predominant testing method. The incidence of testing was found to increase at both 6 months and 12 months after revascularization, suggesting an association with elective follow-up office visits. Furthermore, testing varied according to geographic location. Of those tested, only 11% underwent subsequent cardiac catheterization and only 5% underwent repeat revascularization. CONCLUSIONS: Although there is limited consensus as to the appropriate role of elective stress testing after coronary revascularization, more than one half of all patients in community practice had at least 1 stress test within 24 months of revascularization. Yield on such testing was low: only 5% of patients tested ultimately required repeat revascularization. These findings support the need to define better the role of stress testing after recent revascularization.