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The history and physical examination, rather than routine laboratory, cardiovascular, and pulmonary testing, are the most important components of the preoperative evaluation. The history should include a complete review of systems (especially cardiovascular and pulmonary), medication history, allergies, surgical and anesthetic history, and functional status. s KEY POINTS Laboratory testing should be selective and justified by specific findings on the history or physical examination. Lee et al (Circulation 1999; 100:1043-1049) devised a simple index of cardiac risk based on the presence or absence of six factors: high-risk surgery, ischemic heart disease, congestive heart failure, stroke or transient ischemic attack, insulin-dependent diabetes mellitus, and serum creatinine concentration greater than 2 mg/dL. All patients at risk undergoing surgery should receive a selective beta-blocker such as metoprolol 50 mg twice daily, starting 1 week before surgery. Noninvasive cardiac stress testing is reserved for patients at uncertain or high risk.

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Clinical diagnosis of venous thromboembolic (VTE) disease is often inaccurate because signs and symptoms are nonspecific. Testing for the absence of D-dimer levels in the blood of patients with suspected deep venous thrombosis and pulmonary embolism can assist in ruling out these illnesses. Some highly sensitive D-dimer assays have sufficient specificity to assist in the exclusion of VTE disease. Numerous clinical management trials using D-dimer measurement in association with additional diagnostic tests have shown that it is safe to withhold anticoagulant therapy in selected patients with suspected VTE disease who have negative D-dimer assay results. Applying these diagnostic strategies can potentially decrease the need for radiological testing. The simplicity of measuring D-dimer levels creates the potential for misuse. For safe patient management, clinicians must understand the indications for and limitations of D-dimer measurement in the diagnosis of VTE disease.

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endothelin correlates with the extent of pulmonary hypertension in patients with chronic congestive heart failure. Circulation. 1992;85: 504-509. 11. Buzzard CJ, Pfister SL, Campbell WB. Endothelium-dependent contractions in rabbit pulmonary artery are mediated by thromboxane A2.