How close to surgery is an electrocardiogram (EKG) typically performed?

Timing of Preoperative EKG

For intermediate- and high-risk patients undergoing noncardiac surgery, obtain a preoperative EKG at the time of preoperative assessment, which can be performed days to weeks before surgery, as long as the patient's clinical status remains stable. 1, 2

Risk-Stratified Approach to EKG Timing

Intermediate and High-Risk Patients

• Perform EKG during preoperative evaluation for patients with known cardiovascular disease, those ≥65 years old, or patients with cardiovascular risk factors undergoing intermediate or high-risk surgery 2, 3
• The European Society of Cardiology quality indicators specify that intermediate- and high-risk patients should have an ECG "pre-operatively" without mandating a specific timeframe before surgery 1
• For high-risk patients undergoing non-urgent high-risk surgery, echocardiography should be performed within 3 months preoperatively, suggesting EKG can reasonably be obtained within a similar or shorter timeframe 1

Low-Risk Patients

• Do not obtain routine preoperative EKG for asymptomatic patients undergoing low-risk surgery (including most cosmetic procedures), regardless of when surgery is scheduled 4
• This applies even to patients over 40 years old if they have no cardiovascular risk factors and good exercise tolerance 4

Clinical Context for Timing

When Earlier EKGs Are Acceptable

• An EKG obtained weeks before surgery remains valid if the patient's clinical status is unchanged 1
• Patients with stable cardiovascular disease do not require repeat EKG immediately before surgery if a recent one exists and no new symptoms have developed 2

When Day-of-Surgery EKG Is Needed

• Obtain EKG on day of surgery if new cardiac symptoms develop (syncope, new dyspnea, change in angina pattern, palpitations, extreme fatigue) 1, 3
• Patients with unstable cardiac conditions may require postponement of elective surgery rather than proceeding with same-day EKG 2

Postoperative EKG Timing

Immediate Postoperative Period

• Obtain EKG in the recovery room for all patients undergoing major noncardiac surgery, as this identifies patients at higher risk for major cardiac complications even in low-risk subsets 5
• Continue cardiac monitoring for minimum 48-72 hours after uncomplicated cardiac surgery 1

High-Risk Postoperative Monitoring

• Check troponin and EKG at 24 and 48 hours after surgery in intermediate- and high-risk patients undergoing high-risk noncardiac surgery 1
• For patients with postoperative myocardial injury, perform cardiac evaluation before hospital discharge 1

Common Pitfalls to Avoid

• Do not order "routine" EKGs based solely on age cutoffs without considering cardiovascular risk factors and surgical risk, as this increases costs without improving outcomes 2, 4, 6
• Do not assume an abnormal preoperative EKG necessitates surgery cancellation - in one study, 80% of patients with abnormal EKGs proceeded safely to surgery 7
• Always compare with previous EKGs when available to avoid misinterpreting chronic findings as acute changes 2, 3
• Do not rely on physical examination alone to predict EKG abnormalities - abnormal physical findings predict only 20% of abnormal EKGs 8