Indications for EKG in Non-Cardiac Conditions
An electrocardiogram (EKG) should be performed in patients with non-suspected cardiac issues in specific clinical scenarios including preoperative evaluation for patients over 40 years old, when monitoring medications with known cardiac effects, in patients with symptoms that could have cardiac origins, and in those at high risk of developing cardiac disease. 1, 2
Preoperative Evaluation
- All patients over 40 years old should have a preoperative EKG, even without suspected cardiac disease 1, 2
- Patients being evaluated as donors for heart transplantation or recipients of non-cardiopulmonary transplants should have preoperative EKGs 1
- Preoperative EKGs are not indicated for patients under 30 years old with no risk factors for coronary artery disease 1, 3
- For elective cosmetic surgery in healthy patients without cardiovascular risk factors, routine EKGs are not recommended 3
Medication Monitoring
- EKGs should be performed to assess therapy with medications known to produce cardiovascular effects, such as:
- EKGs are not indicated when monitoring medications known not to influence cardiac structure or function 1
Symptoms That Warrant EKG Despite Non-Cardiac Presentation
- Syncope or near-syncope 1
- New or worsening dyspnea 1
- Extreme and unexplained fatigue, weakness, or prostration 1
- Palpitations 1
- Patients who may have received an overdose of illicit drugs known to have cardiac effects 1
High-Risk Patients
- Patients with diabetes and hypertension or suspected cardiovascular disease should have an EKG 4, 5
- A normal EKG has a 99.3% negative predictive value for ruling out heart failure with reduced ejection fraction in diabetic patients 4
- Approximately 24% of patients with type 2 diabetes have ECG abnormalities, including those without known cardiovascular disease 5
- Periodic follow-up (every 1-5 years) is appropriate for patients at increased risk for developing cardiac disease 1
Age-Based Recommendations
- Baseline EKG is recommended for asymptomatic persons over 40 years of age 1
- Some guidelines recommend a baseline EKG at age 20 years with repeats at ages 40 and 60 years 1
- Routine annual EKGs are not recommended for asymptomatic adults who have had no interval change in symptoms, signs, or risk factors and who have had a normal EKG within the recent past 1, 6
Common Pitfalls to Avoid
- Ordering "routine" EKGs without clinical indication increases healthcare costs without improving outcomes 2, 3, 6
- Failing to compare with previous EKGs when available may result in misinterpretation of chronic findings as acute 2
- Routine EKG testing in low-risk patients can lead to unnecessary downstream cardiac testing and consultations 6
- EKG screening is not sufficiently sensitive to detect coronary artery disease in asymptomatic middle-aged people 7
Special Considerations
- For patients with type 2 diabetes, a normal EKG can effectively rule out heart failure with reduced ejection fraction 4
- In patients with acute symptoms that could be cardiac in origin (even if initially thought to be non-cardiac), an EKG should be performed to rule out acute coronary syndrome 8
- When interpreting EKGs in non-cardiac conditions, always consider the clinical context and compare with previous EKGs when available 2, 8