A 76-year-old man comes to the office for a preoperative evaluation. The patient is scheduled for an elective prostatectomy in 2 weeks. He initially had difficulty urinating and was found to have an enlarged, irregular prostate; subsequent evaluation revealed adenocarcinoma of the prostate. Medical history is notable for hypertension and diet-controlled diabetes mellitus. The patient also had a stroke 6 years ago and has residual right upper extremity weakness. Medications include daily low-dose aspirin, atorvastatin, valsartan, tamsulosin, and finasteride. He walks 2 miles most days and smokes half a pack of cigarettes daily.
Physical examination is normal except for mild weakness in the right upper extremity.
ECG shows normal sinus rhythm at 74/min with occasional premature atrial beats. Hemoglobin is 14.1 g/dL, platelet count is 340,000/mm³, and creatinine is 0.8 mg/dL.
Which of the following is the most appropriate next step in management of this patient?

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11ec193a_974a_9e78_853d_87755f292a2f_MD0002_00 This patient has good functional capacity, 1 clinical predictor (prior stroke) for major cardiac complications, and is undergoing noncardiac, lower-risk surgery. Based on the Revised Cardiac Risk Index (RCRI), he has a low risk (1%) of perioperative cardiac events and may proceed with surgery without any further preoperative cardiac evaluation or intervention. (Although risk estimates vary, the American Board of Internal Medicine calculator uses these estimates for RCRI.) Beta blockers (eg, metoprolol) are indicated for patients with angina, myocardial infarction, heart failure with reduced ejection fraction, or atrial fibrillation. In the past, beta blockers were advocated to reduce the risk of perioperative cardiovascular complications in patients at increased risk. However, the POISE trial showed significantly increased rates of hypotension, stroke, and total mortality in patients given perioperative beta blocker therapy; therefore, these drugs are not recommended for patients without specific indications. Those taking beta blockers for appropriate indications should continue these medications in the perioperative period with close monitoring of heart rate and blood pressure (Choices D and E). (Choices A and B) Pharmacologic or exercise stress testing is often performed prior to surgery for patients with known or suspected cardiac disease or undergoing very high-risk surgery (eg, major vascular surgery). This patient does not have cardiac disease, is physically active, and is undergoing surgery with a lower risk of cardiovascular complications. He does not need preoperative stress testing. Educational objective: Beta blockers are indicated for patients with angina, myocardial infarction, heart failure with reduced ejection fraction, or atrial fibrillation. In the absence of specific indications, beta blockers are not recommended in routine perioperative management. __________ References: 2009 ACCF/AHA focused update on perioperative beta blockade. (http://www.ncbi.nlm.nih.gov/pubmed/19926021) 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/25091544)

A 76-Year-Old Man Comes to the Office for a Preoperative