In the United States alone, an estimated 1 in 9 persons is reported to have undergone at least one surgical procedure in the past year. A major consideration among both primary care physicians and surgeons is how to best stratify patients into low, medium, and high risk categories for adverse surgical outcomes. One of the major risks considered is adverse cardiac and cerebral events (MACCEs). According to the 2024 AHA Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery, physicians should consider such factors as the type of surgery being performed, the use of anesthesia, patient comorbidities, patient functional status, and prior cardiac events when considering the likelihood of MACCEs. Despite this, there remain high rates of overscreening, , particularly in patients with no clear risk factors for adverse cardiac outcomes, and at times to the detriment of overall clinical outcomes. It has long been recognized that there is a disproportionate burden of cardiovascular disease in rural Appalachia, a burden that is likely driven by widespread disparities in access to transportation, medical literacy, and healthcare as a whole. Therefore, we aimed to determine if routine preoperative transthoracic echocardiogram (TTE) was associated with decreased MACCEs in this high-risk population.
Methods
This cross-sectional, retrospective study included patients who were included in the TriNetX database, which contains anonymized electronic medical record data collected from over 150 million patients across 111 healthcare organizations. Our study included patients in the West Virginia University (WVU) healthcare network, which includes over 2.6 million patients. Included patients had undergone at least one surgical procedure from November 14, 2024 to November 14, 2025. The surgery site was unspecified, but included cardiac and noncardiac surgeries. Patients were divided into 2 cohorts for the primary analysis: those who had undergone at least 1 echocardiogram (either transthoracic or transesophageal) in the 6 months preceding surgery (Echo Group) and those who had not (No Echo Group). Secondary analysis included patients who had either TTE or transesophageal echocardiogram in the 6 months before undergoing surgery, who had either intraoperative cardiac arrest or arrhythmia. Patients were excluded if they had a diagnosis of previous intraoperative complication (cardiac arrest, cardiac arrhythmia) before the specified timeframe (November 2024–2025). Demographic and clinical characteristics collected from TriNetX included age, sex, race, ethnicity, and BMI. Laboratory values were reported from measurements collected on the day of the surgery or within the previous 6 months. These included blood urea nitrogen, Cr, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, BNP (B-Type natriuretic peptide), A1c, and left ventricular ejection fraction.
Results
Of the over 2.6 million patients available in the WVU TriNetX network, a total of 1,594,810 patients qualified as eligible for this study. A total of 1,310,320 patients were included in the “No Echo” cohort (NE), and a total of 284,490 patients were included in the “Echo” cohort (E). Our primary analysis examined the risk of an intraoperative adverse cardiac event(s) (ACE), which were defined as either cardiac arrest or cardiac arrhythmia. A total of 20 patients (0.002%) had at least one ACE in “No Echo” group, compared to 80 patients (0.03% of patients) in the “Echo” group. This result reached statistical significance, with a risk ratio of 0.06 (95% CI 0.04–0.09), and risk difference of −0.03% (09% CI −0.04 to −0.02%, p < 0.0001). A total of 130 patients in the “No Echo” and 550 patients in the “Echo” group were excluded due to at least one reported ACE before the observation period.
Patient demographics were comparable across both groups, with the majority of patients identifying as white (89.7% NE, 94.2% E) and not Hispanic/Latino (93.9% NE, 97.1% E). Risk factors for the development of cardiovascular disease and ACEs were also similar across both groups, with overlapping ranges of measured values for blood urea nitrogen, Cr, Cholesterol (Total, low-density lipoprotein, high-density lipoprotein), triglycerides, A1c, BNP, and BMI. Left ventricular ejection fraction was also comparable between both groups (71 ± 10.3% NE, 60 ± 18.1% E).
Our secondary analysis examined patients with a known intraoperative ACE who had undergone an echocardiogram (TTE or transesophageal echocardiogram) in the 6 months preceding surgery in order to determine what, if any, new diagnoses were made on echo. A total of 870 patients met the inclusion criteria ( Table 1 ). Of these patients, 140 had a new diagnosis of heart failure in the 6 months before surgery (16.1% of patients), 70 had a new diagnosis of mitral valve disease (8.05% of patients), 50 had a diagnosis of aortic valve disease or secondary pulmonary hypertension (5.75% of patients), 40 had a diagnosis of cardiomyopathy (4.6% of patients), and 20 had a diagnosis of tricuspid valve disease (2.3% of patients).
Table 1
Diagnoses of patients with echocardiogram (TTE or TEE) in the 6 months preceding intraoperative cardiac event (arrest or arrhythmia)
| Diagnosis | > 6 months (n) | ≤ 6 months (n) |
Difference
(n) |
% Cohort
(n = 870) |
|---|---|---|---|---|
| Heart failure | 130 | 270 | 140 | 16.09 |
| NR Mitral | 140 | 210 | 70 | 8.05 |
| NR Aortic | 130 | 180 | 50 | 5.75 |
| 2* pHTN | 60 | 110 | 50 | 5.75 |
| Cardiomyopathy | 50 | 90 | 40 | 4.60 |
| NR Tricuspid | 100 | 120 | 20 | 2.30 |
| NR Pulmonary | 40 | 40 | 0 | 0 |
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