Age-Based Preoperative Transthoracic Echocardiography, Intraoperative Hypotension, and Postoperative Outcomes in Older Adults Undergoing Noncardiac Surgery: A Regression Discontinuity Analysis.

Summary

In 7,270 elective noncardiac surgery patients aged 60–89 years, a policy threshold at age 75 increased the probability of preoperative TTE by 43.1 percentage points but did not clearly reduce intraoperative hypotension. Mortality, acute kidney injury, unplanned critical care admission, and hospital stay had imprecise estimates, so clinically meaningful benefit or harm could not be excluded.

Key Findings

• Among 7,270 patients, the probability of receiving preoperative TTE increased by 43.1 percentage points at the age-75 policy threshold.
• The estimated effect of TTE on intraoperative hypotension was a 24.8-minute reduction, but the 95% confidence interval ranged from a 71.1-minute reduction to a 21.5-minute increase.
• Point estimates for mortality, acute kidney injury, unplanned critical care admission, and hospital stay generally favored TTE but were imprecise and not conclusive.

Clinical Implications

Routine preoperative TTE should not be automatically ordered solely because a patient is 75 years or older. Preoperative cardiac imaging should instead be guided by symptoms, functional status, known cardiovascular disease, surgical risk, and established guideline-based indications.

Limitations

• This was a single-center retrospective study, and the local treatment effect near age 75 may not generalize to other institutions or age ranges.
• The study was not powered to exclude clinically meaningful effects on mortality, acute kidney injury, or critical care use.

Future Directions

Future studies should evaluate selective, risk-based echocardiography strategies using multicenter pragmatic designs and should identify patient subgroups in whom preoperative TTE changes anesthetic management or improves outcomes.