Who should undergo an electrocardiogram (EKG) as part of their preoperative evaluation for surgical clearance?

Preoperative EKG Recommendations for Surgical Clearance

Preoperative EKG should be performed for patients with known cardiovascular disease, those older than 65 years, and patients with cardiovascular risk factors undergoing intermediate or high-risk surgery, but is not indicated for asymptomatic patients undergoing low-risk procedures. 1

Patient Categories Requiring Preoperative EKG

Definite Indications (Class I)

• All patients with known cardiovascular disease or dysfunction undergoing cardiac or noncardiac surgery 1
• Patients with known heart disease, peripheral vascular disease, or cerebrovascular disease undergoing intermediate or high-risk surgery 1
• Patients older than 65 years, regardless of risk factors 1
• Patients with one or more clinical risk factors (coronary artery disease, heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency) undergoing vascular surgery 1

Consider EKG (Class II)

• Patients with hemodynamically insignificant congenital or acquired heart disease 1
• Patients with minimal to mild systemic arterial hypertension 1
• Patients with infrequent premature complexes without organic heart disease 1
• Patients with no clinical risk factors undergoing vascular surgery 1
• Patients with one or more clinical risk factors undergoing intermediate-risk surgery 1
• Patients of any age with diabetes, hypertension, chest pain, congestive heart failure, smoking history, peripheral vascular disease, inability to exercise, or morbid obesity 1
• Patients with new signs or symptoms of cardiovascular disease 1

EKG Not Indicated (Class III)

• Asymptomatic patients undergoing low-risk surgery 1, 2
• Patients with no risk factors undergoing low-risk surgery 1

Clinical Value of Preoperative EKG

• Abnormal EKG findings are associated with higher incidence of cardiovascular death (1.8% vs 0.3%) 3
• Adding EKG data to clinical risk factors improves prediction of cardiovascular death (C index 0.79 vs 0.72) 3
• However, for low-risk surgery, the absolute difference in cardiovascular death between patients with and without EKG abnormalities is only 0.5% 3
• Bundle branch blocks identified on preoperative EKG are related to perioperative myocardial infarction but do not improve prediction beyond risk factors identified from patient history 4

Age Considerations

• In elderly patients (≥65 years), preoperative EKG is recommended regardless of other factors 1, 5
• In a study of surgical patients aged 65 and over, only 21% had normal preoperative EKGs and 53% had major abnormalities 5
• For elderly patients, preoperative EKG serves as a valuable baseline for interpreting postoperative EKG changes 5

Risk-Based Approach

• For patients with excellent functional capacity (>10 METs) and no symptoms, surgery can generally proceed despite evidence of previous cardiac issues 6
• Poor functional capacity (<4 METs) warrants further cardiac evaluation before surgery 6
• The presence of active cardiac conditions (unstable coronary syndromes, decompensated heart failure, significant arrhythmias) may warrant postponing or canceling elective surgery 6

Common Pitfalls to Avoid

• Ordering "routine" EKGs without clinical indication increases healthcare costs without improving outcomes 2
• Relying solely on EKG findings without considering clinical risk factors may lead to unnecessary testing or interventions 4
• Failing to compare with previous EKGs when available may result in misinterpretation of chronic findings as acute 6
• Overlooking the importance of EKG as a baseline measurement for interpreting postoperative changes in high-risk patients 5