Who should undergo a preoperative electrocardiogram (EKG)?

Preoperative EKG Recommendations

Preoperative EKGs 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 are not indicated for asymptomatic patients undergoing low-risk surgery. 1, 2

Patient Categories Requiring Preoperative EKG

• Patients with known cardiovascular disease or dysfunction undergoing any surgery (cardiac or noncardiac) 1
• Patients older than 65 years, regardless of risk factors 1, 3
• Patients with heart disease, peripheral vascular disease, or cerebrovascular disease undergoing intermediate or high-risk surgery 1
• Patients with one or more clinical risk factors undergoing vascular surgery 1
• Patients with history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease 3

Patient Categories NOT Requiring Preoperative EKG

• Asymptomatic patients undergoing low-risk surgery (including most cosmetic procedures) 2
• Patients with NO cardiovascular risk factors AND good exercise tolerance undergoing low-risk procedures 2

Risk-Based Approach to Preoperative EKG

• Patients with excellent functional capacity (>10 METs) and no symptoms can generally proceed to surgery despite evidence of previous cardiac issues 1
• Poor functional capacity (<4 METs) warrants further cardiac evaluation before surgery 1
• Active cardiac conditions may warrant postponing or canceling elective surgery 1

Clinical Value and Limitations

• Preoperative EKGs serve as a baseline measurement to aid interpretation of post-operative EKG changes 4
• They help detect patients with acute myocardial infarctions or serious arrhythmias in whom surgery should be deferred 4
• However, abnormalities on preoperative EKGs have limited value in predicting postoperative cardiac complications in older patients undergoing noncardiac surgery 5
• Recent research (2024) shows that 48.78% of older surgical patients had abnormal preoperative EKGs, with left axis deviation, left ventricular hypertrophy, and ST segment changes being the most common abnormalities 6

Common Pitfalls to Avoid

• Ordering "routine" EKGs without clinical indication increases healthcare costs without improving outcomes 1, 2
• Failing to compare with previous EKGs when available may result in misinterpretation of chronic findings as acute 1
• Relying solely on age as a criterion for EKG ordering without considering other risk factors may lead to unnecessary testing 3, 5
• Underestimating the prevalence of abnormal EKGs in elderly patients - studies show that only 21% of surgical patients aged 65 years and over had normal preoperative EKGs 4

Special Considerations

• For patients with limited or unknown functional capacity, clinical judgment should determine if EKG testing would impact perioperative management 2
• Patients with good exercise tolerance have demonstrated adequate cardiovascular reserve, making additional testing less valuable 2
• The presence of comorbidities, age ≥70 years, history of angina, and smoking history are strong risk factors for abnormal EKGs 6