A 75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypeension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. Which of the following is the most appropriate next step in his preoperative workup?

The patient should undergo persantine thallium stress testing followed by echocardiography to assess his need for coronary angiogram with possible need for angioplasty, stenting, or surgical revascularization prior to repair of his hernia. Although exercise stress testing is an appropriate method for evaluating a patient's cardiac function preoperatively, this patient's functional status is limited by his peripheral vascular disease and therefore a pharmacologic stress test would be the preferred method of cardiac evaluation. An ECG should be performed in this patient with a history of cardiovascular disease, hypeension, and diabetes, but a normal ECG would not preclude fuher workup. While myocardial infarction (MI) within 6 months of surgery is considered to increase a patient's risk for a cardiac complication after surgery using Goldman's criteria, a remote history of MI is not prohibitive for surgery in and of itself.