No further diagnostic testing is needed for this patient's preoperative cardiovascular risk assessment. This patient is scheduled to undergo surgery (total knee arthroplasty) and has an indeterminate functional capacity, but he does not have coronary artery disease or its equivalents (chronic kidney disease, cerebrovascular disease, heart failure, or diabetes mellitus). Whether a risk calculator (for example, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator) or a simplified approach to perioperative cardiac risk assessment (such as the Revised Cardiac Risk Index) is used, this patient's risk for major adverse cardiac events would be low. No further diagnostic testing is therefore indicated.

As outlined by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, noninvasive pharmacologic cardiac stress testing is not appropriate for an asymptomatic patient with low risk of cardiac complications. Such testing is both low yield and prone to false-positive results. Instead, cardiac stress testing may be considered in patients with elevated cardiac risk and poor or indeterminate functional capacity if the results will alter perioperative management.

Resting echocardiography is useful for evaluating structural heart disease (such as valvular disease or cardiomyopathy). It is not an appropriate modality for coronary artery disease assessment. Because this patient has no signs or symptoms of structural heart disease, resting echocardiography is not indicated.

The utility of cardiac biomarkers such as serum troponin in preoperative cardiac risk assessment is still under debate, and ACC/AHA guidelines do not recommend their use in perioperative risk stratification. Even if their use was considered for risk stratification, it would not be appropriate in patients without other cardiac risk factors due to the potential for false-positive results in this population.