Clinician Agreement With Perioperative Cardiovascular Evaluation Guidelines and Clinical Outcomes

The American College of Cardiology/American Heart Association (ACC/AHA) published guidelines for preoperative cardiac risk stratification in 1996. Although clinician practice may differ from the guidelines, it remains unclear whether deviation from these guidelines affects clinical outcomes. This study sought to determine if discordance between clinician practice and the ACC/AHA guidelines affects perioperative cardiac outcomes. Eight hundred twenty-three patients who underwent 864 consecutive preoperative evaluations performed from 1995 to 1997 at a tertiary care academic medical center were prospectively followed. Clinician recommendations for preoperative cardiac testing were compared with ACC/AHA guideline recommendations. Frequencies of perioperative cardiac complications were compared between concordant and discordant testing recommendations. There were 33 perioperative cardiac complications (3.8%). Overall, there was no difference in the frequency of complications when there was discordance with the ACC/AHA guidelines compared with concordance (4.1% vs 3.7%, p = 0.81). The ACC/AHA guidelines recommended cardiac testing for 236 patients (27.3%). Clinicians ordered testing in half of those cases (n = 112). There was a lower frequency of cardiac complications when clinicians did not perform testing as recommended by the ACC/AHA guidelines (3.2% vs 10.7%, p = 0.02). Conversely, clinicians ordered cardiac testing in 45 patients (7%) when not recommended by the guidelines. Patients in this group had a trend toward more cardiac complications (6.7% vs 2.4%, p = 0.09). In conclusion, the failure of clinicians to follow the ACC/AHA guidelines when perioperative testing was recommended did not result in a higher frequency of cardiac complications.