Decision-Making Dilemma in Preoperative Cardiac Evaluation: Should We Turn the Page or Close the Book?

Coronary artery disease is one of the most dreadful and life-threatening diseases out of all cardiac diseases. The diagnosis and management of coronary artery disease comprise stepwise approaches. All these approaches are mostly guideline-driven. While the majority of the time, guidelines help us take the most appropriate care, exceptions do exist. For example, patients may have unusual risk factors and abnormal test results; however, they do not fit into the guideline algorithm to proceed further.  This case report of a 68-year-old male patient depicts a true example of such a situation. He presented to the cardiologist's office for pre-operative cardiac evaluation for urological surgery. In view of associated risk factors, an exercise stress test was done, which showed critical abnormalities. As per the pre-operative cardiac assessment guidelines, the patient did not meet the criteria for further testing. However, a clinician's strong judgment and persistent negotiation superseded those barriers. Given critical abnormalities of the exercise stress test, the patient underwent cardiac catheterization. He was found to have triple vessel disease on cardiac catheterization. The scheduled surgery was withheld, and the patient underwent a coronary artery bypass graft. This life-threatening condition could have been easily missed if only the guidelines were to be followed. While guidelines cover a significant portion of the bell curve, this case report represents the importance of not missing the tail ends of the curve. It enhances the importance of thinking out of the box based on clinical training and expertise.