Routine Laboratory Cardiac Testing is Not Cost Effective Following Carotid Endarterectomy
Arthelma C. Tyson, MD, Celsa M. Tonelli, BS, Amira Alkhatib, BS, Shailraj Parikh, MD, Kuldeep Singh, MD, Saqib Zia, MBBS, Jonathan Schor, MD, FACS, Jonathan Deitch, MD, FACS.
Staten Island University Hospital, Staten Island, NY, USA.
OBJECTIVES: Routine laboratory testing to rule out myocardial infarction (MI) after carotid endarterectomy (CEA) is common in many centers. Its utility in this patient population has not been thoroughly investigated. We hypothesize that routine testing for MI in post-CEA patients is of low-yield and not cost-effective.
METHODS: A retrospective review of 291 consecutive CEAs from February, 2011 - July, 2015 was performed. Two patients were excluded: one for postoperative non-cardiac death and one for preoperative MI. Patient demographics, medications, medical history, type of anesthesia, and postoperative laboratory results were reviewed. All patients had troponin-I and CK-MB levels taken postoperatively. A patient was judged to have an MI if: troponin-I was greater than or equal to 0.6ng/mL or CK-MB > 6.3ng/mL. The incidence of postoperative MI was recorded and a cost analysis performed.
RESULTS: The mean age was 70.2 (range 42-92). 59.5% were male. 92.4% had a history of hypertension. Preoperatively, 57.4% were on beta-blocker therapy, 86.5% on aspirin, and 52.2% both. 80.6% were on preoperative statin therapy. 26.9% had prior history of MI (37.2% within 5 years of surgery). 56.4% of patients had a prior coronary intervention (27.6% percutaneous, 28.7% CABG, 11% both). All patients received general anesthesia. The mean procedure time was 121.5 minutes (range 62-258). The mean post-operative length of stay was 2.6 days. Eight patients (2.7%) were judged to have acute MI, one of which was symptomatic. 3 of the 8 (38%) had a prior history of MI. The asymptomatic patients had a range in peak troponin-I from 0.52 to 3.64ng/mL and CK-MB 11.8 to 24 ng/mL. The symptomatic patient had chest pain and bradycardia. The patient had a peak troponin-I of 1.59ng/mL with CK-MB 11.5ng/mL. All patients were treated medically. The cost per troponin-I and CK-MB is $27.78 and $31.44 respectively in our institution. We estimate that eliminating routine post-operative troponin-I and CK-MB testing in post-operative CEA patients would have saved an estimated $51,343 over the course of the studied population.
CONCLUSIONS: Routine postoperative cardiac laboratory testing in asymptomatic patients following CEA increases hospital cost. The low overall rate of postoperative MI suggests that cardiac testing is best reserved for symptomatic patients or those with clinical suspicion for MI.
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