Is a septal infarction finding on an electrocardiogram (EKG) in an asymptomatic patient a contraindication to surgery?

Septal Infarction Finding on EKG in Asymptomatic Patients: Implications for Surgery

A septal infarction finding on EKG in an asymptomatic patient is not a contraindication to surgery, particularly for low-risk procedures, and does not require additional cardiac testing or postponement of surgery.

Assessment of Surgical Risk in Patients with EKG Abnormalities

The approach to managing patients with septal infarction findings on EKG depends on several factors:

Risk Stratification Based on Procedure Type

1. Low-Risk Procedures:

   • For very low-risk procedures (cardiac risk <1%) such as cataract surgery, even patients with multiple cardiac risk factors do not require additional testing 1
   • Exercise testing is contraindicated in symptomatic aortic stenosis patients but has been shown to be useful in asymptomatic patients 2

2. Intermediate to High-Risk Procedures:

   • For patients undergoing intermediate or high-risk surgery, the presence of EKG abnormalities should be evaluated in context with other clinical factors
   • The European Society of Cardiology guidelines state that asymptomatic patients with good exercise tolerance have good prognosis even with severe stenosis 2

Clinical Decision-Making Algorithm

1. Assess patient symptoms:

   • If truly asymptomatic, proceed with risk stratification
   • Consider exercise testing to confirm asymptomatic status if uncertain 2

2. Evaluate procedure risk:

   • Low-risk procedures: Proceed without additional testing
   • Intermediate/high-risk procedures: Consider additional evaluation

3. Consider EKG findings in context:

   • Isolated septal infarction pattern without clinical symptoms may represent:
     • Previous silent MI
     • A pseudo-infarction pattern (as seen in some non-cardiac conditions) 3
     • Normal variant in some patients

Recommendations Based on Procedure Risk

For Low-Risk Surgery:

• Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk procedures (Class III: No Benefit) 1
• Routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery (Class III: No Benefit) 1

For Intermediate/High-Risk Surgery:

• In asymptomatic patients, the septal infarction finding should be documented as a baseline
• Continue all cardiac medications through the perioperative period, especially antiplatelet therapy, beta-blockers, and statins 1
• Consider the following factors when deciding on additional testing:
  • Patient's functional capacity
  • Presence of other cardiac risk factors
  • Urgency of the procedure

Important Caveats and Pitfalls

1. Distinguishing True Septal Infarction from Pseudo-Infarction Patterns:

   • Some conditions can mimic septal infarction on EKG without actual myocardial damage 3
   • Vectorcardiography may be more sensitive than standard ECG in detecting septal infarctions 4

2. Avoiding Unnecessary Testing:

   • Ordering stress tests or echocardiograms for asymptomatic patients before low-risk procedures increases costs without improving outcomes 1
   • A 2012 Cochrane review reinforced that abnormal preoperative test results did not predict outcomes in low-risk procedures 2

3. Recognizing True Contraindications:

   • Symptomatic patients with evidence of active ischemia
   • Patients with ventricular septal rupture (a rare complication of MI with high mortality) 2, 5

Conclusion

The presence of a septal infarction pattern on EKG in an asymptomatic patient should be noted but does not contraindicate surgery. The decision to proceed should be based on the type of surgery, patient's functional status, and overall cardiovascular risk profile. For low-risk procedures, no additional testing is needed, while for higher-risk procedures, individualized assessment may be warranted.