What is the proper procedure for ordering an electrocardiogram (EKG)?

How to Order an EKG

Order an EKG for any patient with cardiac symptoms (chest pain, dyspnea, palpitations, syncope), known cardiovascular disease, or before starting medications that affect cardiac conduction—do not order routinely in asymptomatic patients without cardiac risk factors. 1, 2, 3

Clear Indications for Ordering an EKG

Symptomatic Patients (Class I - Always Order)

• Syncope or near-syncope 1, 2
• Chest pain or unexplained change in usual angina pattern 1, 2
• New or worsening dyspnea 1, 2
• Palpitations 1, 2
• Extreme and unexplained fatigue, weakness, or prostration 1, 2

Patients with Known Cardiovascular Disease (Class I - Always Order)

• All patients with documented heart disease require a baseline ECG during initial evaluation, as this provides instantaneous information about arrhythmias, conduction defects, chamber enlargement, myocardial hypertrophy, ischemia, necrosis, and pericardial inflammation 1, 2
• Patients on therapy known to produce ECG changes that correlate with therapeutic response or disease progression 1, 2
• Patients on therapy that may produce adverse cardiac effects detectable by ECG 1, 2

Preoperative Evaluation (Class I - Always Order)

• All patients with known cardiovascular disease undergoing any surgery (cardiac or noncardiac) require a recent preoperative ECG 1, 2

Before Starting Specific Medications (Mandatory ECG)

• Patients starting lacosamide who have cardiac history including syncope, near-syncope, chest pain, palpitations, or known heart disease 4
• Patients on drugs that prolong PR interval (beta-blockers, calcium channel blockers, digoxin) before adding lacosamide 4
• Patients on any cardiovascular medications before starting lacosamide 4

When NOT to Order an EKG (Class III - Do Not Order)

• Asymptomatic patients without cardiac risk factors—guidelines recommend against routine screening ECGs even in those with long-term cardiovascular risk 3
• Patients receiving therapy not known to produce ECG changes or affect cardiac conditions 1, 2
• Adult patients with benign, nonprogressive cardiovascular conditions at routine follow-up visits without clinical changes 1
• Routine baseline ECGs for future emergency comparison have little value and should be reconsidered 5

Special Considerations for ADHD Medications

Do not routinely order ECGs before starting ADHD medications—instead obtain thorough cardiac history and physical examination, reserving ECG only for patients with identified risk factors 6

Cardiac History to Obtain (Instead of Routine ECG):

• Personal history: syncope/near-syncope, chest pain/palpitations, exercise intolerance, unexplained shortness of breath, cardiac surgery, or known heart disease 6
• Family history: sudden unexplained death before age 50, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, or inherited arrhythmia syndromes 6
• Order ECG only if positive findings on history or physical examination 6

Follow-Up ECG Ordering

When to Repeat ECGs (Class I)

• Any change in symptoms, physical signs, or relevant laboratory findings 1, 2
• After initiation of drug therapy, changes in therapy, or addition of drugs with cardiac effects 2
• Serial ECGs until disease process stabilizes (may require multiple recordings over minutes, hours, days, weeks, or years depending on condition) 1

Specific Follow-Up Scenarios:

• Just before cardioversion, immediately after, and before discharge 2
• After cardiac or extensive pulmonary surgery until condition stabilizes and before discharge 2
• After pacemaker insertion/revision, when malfunction suspected, after lead threshold maturation, and at periodic intervals 2

Common Pitfalls to Avoid

• Do not order ECGs in patients receiving non-cardiac therapy that doesn't affect the heart 1, 2
• Do not rely solely on computerized interpretation algorithms—they can be erroneous and the physician must verify the reading 3, 7
• Always compare current ECG with previous tracings when available 7
• Do not order routine screening ECGs as "baselines" for future emergency comparison—this practice has minimal clinical utility 5