Does a patient with a normal electrocardiogram (EKG) from June need another EKG before undergoing open rotator cuff repair surgery this month?

Preoperative EKG Requirements for Rotator Cuff Repair

A repeat EKG is not necessary for this 45-year-old asymptomatic patient undergoing open rotator cuff repair with a normal EKG from June, as the procedure is considered intermediate-risk and the patient remains clinically stable within an acceptable timeframe.

Risk Stratification and EKG Timing

Open rotator cuff repair is classified as an intermediate-risk surgical procedure (not low-risk), which typically warrants consideration of preoperative cardiac evaluation 1. However, the key determining factors are:

• Patient age and cardiac risk factors: At 45 years old without mentioned cardiac disease, this patient falls into a lower-risk demographic 1
• Time interval from previous EKG: The ACC/AHA guidelines indicate that for stable patients, an interval of 1 to 3 months between obtaining a 12-lead EKG and elective surgery is adequate 1
• Clinical stability: The patient had a normal EKG in June and is scheduled for surgery "this month," suggesting a timeframe of approximately 1-4 months 1

Guideline-Based Recommendations

The 2014 ACC/AHA perioperative guidelines provide clear direction:

• Class IIa recommendation: Preoperative resting 12-lead EKG is reasonable for patients with known coronary heart disease or significant structural heart disease, except for low-risk surgery 1
• Class IIb recommendation: Preoperative resting 12-lead EKG may be considered for asymptomatic patients without known coronary heart disease, except for low-risk surgery 1
• Class III (No Benefit): Routine preoperative resting 12-lead EKG is not useful for asymptomatic patients undergoing low-risk surgical procedures 1

Clinical Decision Algorithm

For this specific patient:

1. Assess for new cardiac symptoms: If the patient remains asymptomatic with no interval changes in symptoms (chest pain, dyspnea, syncope, palpitations), proceed without repeat EKG 1, 2

2. Verify timeframe: Since the June EKG falls within the 1-3 month window considered adequate for stable patients, it serves as an appropriate baseline 1

3. Consider surgical risk: While rotator cuff repair is intermediate-risk, the patient's age (45 years) and absence of known cardiovascular disease place him in a lower-risk category 1

Important Caveats

Repeat EKG would be indicated if:

• New cardiac symptoms develop (chest pain, dyspnea, syncope, palpitations, or unexplained fatigue) 1, 2
• The patient has known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other structural heart disease 1
• More than 3 months have elapsed since the June EKG and the patient has cardiac risk factors 1
• Any change in clinical status or new cardiovascular medications 1, 2

Practical Considerations

The preoperative EKG serves two purposes: prognostic information and providing a baseline for postoperative comparison 1. For this asymptomatic 45-year-old patient with a recent normal EKG, the marginal benefit of repeating the test does not outweigh the cost and delay, provided the timeframe remains within 1-3 months and clinical stability is confirmed 1.

The surgical team should document that the patient remains asymptomatic and clinically stable since the June EKG, which satisfies the preoperative cardiac evaluation requirements 1, 2.