What stress test is recommended for a male patient with known triple vessel disease, not taking medications due to religious reasons, and planning to undergo eye surgery?

Stress Testing for Preoperative Eye Surgery in Triple Vessel Disease

For this patient with known triple vessel disease undergoing eye surgery, routine preoperative stress testing is not recommended—proceed directly to surgery with appropriate perioperative medical management and monitoring. 1, 2

Rationale for Not Performing Stress Testing

Eye Surgery is Low-Risk

• Eye surgery is classified as a low-risk procedure (<1% risk of major adverse cardiac events), and current guidelines explicitly recommend against routine stress testing for low-risk procedures regardless of patient cardiac risk factors. 1, 2
• The 2024 ACC/AHA guidelines state that preoperative stress testing should not be performed in stable patients undergoing low-risk noncardiac surgery because it does not change management or improve outcomes. 1

Known Coronary Disease Does Not Change This Recommendation

• The patient already has established triple vessel disease, so stress testing would not provide new diagnostic information about the presence of coronary artery disease. 1
• The purpose of preoperative stress testing is not to identify undiagnosed CAD but to identify patients with left main disease or severe multivessel disease with reduced ejection fraction who might benefit from revascularization—and even in those cases, contemporary evidence shows routine preoperative revascularization does not reduce mortality or MI risk. 1

Critical Management Considerations

The Medication Issue is More Important Than Testing

• The fact that this patient is not taking medications due to religious reasons is a far more significant concern than whether to perform stress testing. 1
• Patients with known triple vessel disease who are not on guideline-directed medical therapy (aspirin, statins, beta-blockers if indicated) have substantially higher perioperative risk. 1
• Consider respectful discussion about perioperative medical management, even if temporary, as this directly impacts morbidity and mortality more than any stress test result. 1

Risk Stratification Already Established

• Triple vessel disease with poor exercise capacity carries an annual mortality rate of 9% compared to 4% with good exercise capacity. 3
• However, for low-risk surgery like eye procedures, this baseline cardiac risk does not justify stress testing because the surgical stress itself is minimal. 1, 2

When Stress Testing WOULD Be Appropriate (Not This Case)

For context, stress testing would only be considered if: 1, 2

• The surgery was elevated-risk (≥1% MACE risk—such as major vascular, intraperitoneal, or intrathoracic procedures)
• AND the patient had poor functional capacity (<4 METs)
• AND the test results would actually change perioperative management
• AND the patient had high-risk features suggesting left main or severe multivessel disease with reduced ejection fraction

Recommended Approach for This Patient

Proceed Directly to Surgery With:

• Optimization of perioperative monitoring given known triple vessel disease 1
• Continuous ECG monitoring during and immediately after the procedure 1
• Careful hemodynamic management to avoid tachycardia and hypotension 1
• Discussion with anesthesia about the patient's cardiac history and medication status 1

Common Pitfall to Avoid

• Do not order stress testing simply because the patient has significant coronary disease—the type of surgery determines testing need, not the severity of underlying cardiac disease. 1, 2
• Delaying low-risk surgery for cardiac testing increases overall morbidity without improving outcomes. 2

If Stress Testing Were Performed (Against Guidelines)

Should you decide to test despite recommendations against it, the choice would be: 4

• Pharmacological stress test (regadenoson/Lexiscan with myocardial perfusion imaging or dobutamine stress echocardiography) if the patient cannot exercise adequately
• Exercise stress test only if the patient can achieve ≥4-5 METs and has interpretable baseline ECG 5, 4

However, this testing is not indicated for low-risk eye surgery and would represent inappropriate resource utilization. 1, 2