As discussed in this article, approximately 5 million patients each year may suffer a perioperative adverse cardiac event. It is difficult to identify patients at risk for perioperative cardiac morbidity and potentially prevent this complication. Hundreds of studies have been done to identify preoperative testing which might influence our ability to control perioperative cardiac outcomes, a confusing body of literature to utilize in everyday clinical practice.

This article addresses the problem of how to interpret prior studies with an abbreviated review of the current knowledge about how to identify and then possibly test the patient with suspected cardiac disease. A brief history of the role of preoperative testing and clinical predictors of CAD is presented at the beginning of the article. Subsequently, each type of specialized testing is examined with a comment on its usefulness. The last part of the article integrates the knowledge of the usefulness of each test with a suggestion for how to proceed in a specific situation (e.g., the patient with no history of CAD but with risk factors for CAD). At the end of the article, a chart is presented which summarizes the conclusions of the article.

A limitation of this study is the lack of discussion of other preoperative testing schemes, which have been presented previously in the literature. Most importantly, the scheme presented by the American College of Cardiology/American Heart Association Task Force should have been compared and contrasted to the paradigm offered in this article (see Circulation. 1996:93:1278-317; JACC. 1996;27(4):910-48; and executive summary in Anesth Analg. 1996;82:854-60). Further, each test of cardiac function is not described in detail, nor are the articles about each specific test (although this is not necessarily the goal of this article). Lastly, the paradigm does not address the type of surgery that the patient is to undergo-a very important consideration for how aggressively to test a patient preoperatively.

A significant benefit of this article is its logic, ease of reading and its simplicity. It lays out a strategy, which we all can follow instead of calling a "cardiology consult" as a reflex when faced with the patient with suspected CAD. In the event that our cardiology colleagues are consulted, this article also helps us to interpret the true implication of positive and negative test results.

Dr. Mangano correctly points out in his article that no one test can mimic all of the stress responses surrounding a surgical procedure, and that the utility of any single perioperative test is limited. The challenge is to develop a preoperative assessment plan, which is flexible, logical and includes what is known about the real benefit of individual tests of cardiac function. Dr. Mangano has presented his paradigm to meet this challenge. He further challenges us to use this information, modifying it to meet individual practitioner skills, and "seize the opportunity to be the primary medical caregiver."