When should an electrocardiogram (EKG) be performed during pre-operative physical evaluation?

When to Perform Preoperative EKG

For patients with known cardiovascular disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or structural heart disease undergoing elevated-risk surgery, obtain a preoperative 12-lead EKG to establish baseline and guide perioperative management. 1

Risk-Stratified Approach to Preoperative EKG

High-Risk Patients (EKG Recommended)

Patients with known cardiovascular conditions:

• Known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease undergoing elevated-risk surgery should receive a preoperative resting 12-lead EKG 1
• Patients with active symptoms of cardiovascular disease (chest pain, dyspnea, undiagnosed palpitations, tachycardia, syncope, or murmurs) undergoing elevated-risk surgery should have preoperative EKG 1

Vascular surgery patients:

• All patients with at least one clinical risk factor undergoing vascular surgical procedures should have preoperative EKG 1
• Even patients with no clinical risk factors undergoing vascular procedures may reasonably receive preoperative EKG 1

Intermediate-Risk Patients (EKG May Be Reasonable)

Asymptomatic patients undergoing elevated-risk surgeries:

• For asymptomatic patients without known cardiovascular disease undergoing elevated-risk surgeries, preoperative 12-lead EKG may be considered to establish baseline and guide perioperative management 1
• This is particularly valuable because a baseline EKG allows comparison if postoperative complications develop 1

Age-based considerations:

• Patients older than 65 years undergoing intermediate or high-risk surgery should have preoperative EKG 2
• Age greater than 65 years is an independent predictor for significant preoperative EKG abnormalities that may affect management 3

Patients with cardiovascular risk factors:

• Patients with at least one clinical risk factor undergoing intermediate-risk operative procedures may reasonably receive preoperative EKG 1
• Specific risk factors that predict significant EKG abnormalities include history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease 3

Low-Risk Patients (EKG NOT Recommended)

Asymptomatic patients undergoing low-risk surgery:

• Routine preoperative resting 12-lead EKG is not recommended for asymptomatic persons undergoing low-risk surgical procedures, as it does not improve outcomes 1
• This includes most cosmetic procedures in healthy patients 4
• Ordering routine EKGs without clinical indication increases healthcare costs without improving outcomes 2, 4

Clinical Decision Algorithm

Step 1: Assess surgical risk

• Low-risk surgery (e.g., most cosmetic procedures, minor orthopedic): No EKG needed for asymptomatic patients 1
• Intermediate-risk surgery: Consider patient factors (see Step 2)
• Elevated-risk/vascular surgery: Proceed to Step 2

Step 2: Evaluate patient cardiovascular status

• Known cardiovascular disease OR active cardiac symptoms → Obtain EKG 1
• Age >65 years AND intermediate/high-risk surgery → Obtain EKG 2
• Cardiovascular risk factors (heart failure, angina, MI history, high cholesterol, severe valvular disease) AND intermediate/elevated-risk surgery → Consider EKG 1, 3
• Asymptomatic, no risk factors, good functional capacity → No EKG needed 1, 4

Step 3: Interpret new abnormalities

• If preoperative EKG shows new abnormalities (ST-segment changes, T-wave inversions, LV hypertrophy, pathologic Q-waves, Mobitz type II or higher AV block, bundle branch block, QT prolongation, or atrial fibrillation), further evaluation is reasonable to refine cardiovascular risk assessment 1

Important Caveats

Common pitfalls to avoid:

• Do not order routine EKGs based solely on age cutoffs without considering surgical risk and patient factors 1, 5
• Abnormalities on preoperative ECGs in geriatric patients are common but do not independently predict postoperative cardiac complications when clinical factors are considered 5
• Always compare new EKGs with previous tracings when available to avoid misinterpreting chronic findings as acute 2

Recognition of specific findings:

• A prolonged QT interval on preoperative EKG may inform selection of anesthetics, postoperative antiemetics, or antibiotic therapy 1
• Incidental Q-waves or bundle branch block in asymptomatic patients may indicate coronary artery disease but should not automatically lead to coronary revascularization before noncardiac surgery 1

Timing considerations:

• An EKG obtained days to weeks before surgery remains valid if the patient's clinical status is unchanged 2
• Obtain EKG on day of surgery if new cardiac symptoms develop (syncope, new dyspnea, change in angina pattern, palpitations, extreme fatigue) 2