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Teachable Moment
Less Is More
August 2015

Preoperative Testing—A Bridge to NowhereA Teachable Moment

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2School of Public Health, Division of Epidemiology, University of California, Berkeley
  • 3Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2015;175(8):1272-1273. doi:10.1001/jamainternmed.2015.2100

A 61-year-old man presented to his primary care physician reporting increasing right lower extremity discomfort after walking. The patient was a former smoker and had a history of dyslipidemia, hypertension, type 2 diabetes mellitus, carotid endarterectomy, and remote stenting of the right common iliac artery. Angiogram confirmed a right superficial femoral artery occlusion and distal 50% stenosis with ankle-brachial index showing moderate distal arterial disease. The patient initiated a walking program and his medical therapy was optimized, but his symptoms progressed over the next 12 months. He was referred to a vascular surgeon who requested preoperative cardiac “clearance” and referred him for cardiac stress testing, although there was no history of chest pain or myocardial infarction. The patient’s ambulation was limited by lower extremity pain, but he described no other limits on activity. A persantine myocardial perfusion single-photon–emission computed tomographic scan showed a normal ejection fraction, normal biventricular function and size, and no evidence of prior infarction or regional ischemia but did identify an equivocal transient ischemic dilatation at rest. Given this result, coronary angiography was ordered and showed multivessel stenosis: 60% left main, 90% left anterior descending, and 80% posterior descending arteries. The patient did not undergo percutaneous intervention. Instead, he was referred to a cardiothoracic surgeon for coronary artery bypass grafting (CABG) to manage coronary artery disease prior to consideration of lower extremity intervention. All the while, he continued to have lower extremity claudication and was without chest symptoms.

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