I read with interest the articles on the preoperative evaluation of the cardiac patient for noncardiac surgery [1, 2]. As a board-certified internist and anesthesiologist, I have come to realize the importance of a combined internal medicine-anesthesiology perioperative approach. In the past, these two fields have been separate. Given the present controversy about the usefulness of preoperative testing, I believe we should once again rely on our basic clinical skills.

Let us step back for one moment from this technological approach and focus on our own medical intuition. The bottom line is that the sicker patients have more illnesses and that their outcome after major surgery is not as secure as in healthier patients. Aggressive standard medical and anesthesia management in the perioperative period improves outcome by controlling the perioperative stress response, postoperative tachycardia, and pain. We know that epidural analgesia reduces the hypercoagulable postoperative state [3].

As Dr. Bodenheimer [1] discussed, we should ask one basic question: "Can this patient reasonably have noncardiac surgery?" Unfortunately, this question assumes that all of the other basic questions have already been answered. We still need some universally accepted answers to the following: 1) What is perioperative myocardial ischemia? 2) Are we efficient in detecting it? 3) Has the treatment of it changed outcome? 4) Is there a correlation between perioperative ischemia and a true myocardial infarction [4]?

Preoperative assessment is not an exact science. No test will conclusively help us prevent a true catastrophic event. We should aggressively manage medical disease and treat surgery as one hurdle in our patients' lives. As Fleisher and Eagle [2] recommended, "the indications for revascularization [should be] reserved for those in whom it may improve symptoms or enhance long-term outcome." Thus, perioperative management must involve a symbiotic relationship between the internist and anesthesiologist.