Preoperative assessment of the patient with cardiac disease.

Assessment of the patient with cardiovascular disease is a challenging problem, especially for the subset of patients undergoing surgery. Perioperative cardiac morbidity affects more than 1.5 million people annually in the United States, and consumes more than +20 billion per year in health care resources. Solution of the problem initially had been addressed using routine historical and clinical evaluations and risk indices. More recently, nonroutine preoperative cardiovascular testing has been recommended, including exercise and Holter electrocardiography, radionuclide ventriculography, stress echocardiography, and dipyridamole thallium scintigraphy. Each of these tests has strengths and limitations that are addressed in this review. Paradigms for preoperative assessment of high-risk patients, based on the presence of coronary disease and the functional status of the patient, are presented and discussed. Diagnostic and therapeutic approaches for patients at high risk remain challenging; the mandate is for large-scale clinical trials to evaluate both the therapeutic and cost effectiveness of new preoperative assessment strategies.