Assessment of patients with heart disease for fitness for noncardiac surgery

The tendency in medicine over the past decade is to decrease preoperative testing, as the evidence for improved outcomes for these often expensive procedures is lacking. Population-based management decisions are often steered by clinical trials, cost-effectiveness analysis, and resource allocation. However, few doctors take care of populations. Most of us care for individuals. Evidence-based paradigms based on population medicine define the most effective management scheme for the vast majority of patients, but not for every patient. Individual patient decisions by attending physicians are not consistently based on evidence but are often made in the context of what would I do if it was my mother? with the premise that more information is better. Should every patient undergoing repair of an abdominal aortic aneurysm undergo dipyridamole or dobut-amine stress testing? The evidence supports not. Nonetheless, the practice in many centers is to obtain a dipyridamole or adenosine thallium stress test even if the patient is asymptomatic. Despite the reassurances provided by large clinical trials, practitioners do not consistently adhere to their recommendations and often rely on tradition, anecdote, and impression in their decision-making. If physicians are to remain the dispensers of medical care and resources, then we need to be cognizant of the effects of our decisions on all patients, not just the one sitting in the examination room. Exorbitant sums spent on unnecessary testing exhausts valuable resources that could be diverted to the more needy. Unfortunately, the risk of uncertainty and medicolegal liability results in more testing than is often indicated.