Can a patient with abnormal EKG findings, including sinus bradycardia, left axis deviation, left atrial enlargement, LVH, and evidence of old infarct, be cleared for laminectomy?

Preoperative Clearance for Laminectomy with Abnormal ECG Findings

This patient can proceed to laminectomy with appropriate perioperative cardiac risk management, but requires further evaluation before surgery to optimize safety. The ECG findings represent chronic cardiac abnormalities rather than acute pathology, and the presence of an old anterior infarct is the most significant concern requiring additional assessment 1.

Risk Stratification Based on ECG Findings

The patient's ECG demonstrates several abnormalities that need to be categorized by clinical significance:

Minor abnormalities (per Novacode criteria):

• Left axis deviation/anterior fascicular block 1
• Left atrial enlargement 1
• LVH by voltage criteria only 1
• Sinus bradycardia of 55 (within normal range) 1

Major abnormality requiring attention:

• Evidence of old anterior infarct (Q waves suggesting prior silent MI) 1

The incomplete bundle-branch block from the prior ECG and current left anterior fascicular block represent conduction system disease but are classified as minor abnormalities 1.

Required Preoperative Evaluation

For a patient with known coronary heart disease (evidenced by old infarct) undergoing elevated-risk surgery like laminectomy, a preoperative 12-lead ECG is reasonable to establish baseline and guide perioperative management 1. Since this has already been obtained, the next steps are:

Immediate Assessment Needed:

• Compare with all prior ECGs to determine if the old anterior infarct finding is truly old or represents interval change 1
• Assess current cardiac symptoms: chest pain, dyspnea, exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea 1, 2
• Obtain transthoracic echocardiogram to evaluate:
  • Left ventricular systolic function and ejection fraction 2, 3
  • Regional wall motion abnormalities confirming prior infarction 4, 3
  • Severity of LVH and whether accompanied by repolarization abnormalities 1
  • Diastolic function 1

Risk-Based Additional Testing:

If the patient has 3 or more clinical risk factors (age ≥70, history of MI, angina, heart failure, cerebrovascular disease, diabetes, renal insufficiency), stress testing with imaging should be performed 3. Given the old anterior infarct, this patient has at least one major risk factor.

For patients with abnormal resting ECGs, stress echocardiography or nuclear perfusion imaging is preferred over standard exercise ECG because they are more accurate in detecting ischemia 2, 3.

Clinical Decision Algorithm

If echocardiogram shows:

1. Normal or mildly reduced LV function (EF >35%) without extensive wall motion abnormalities:

   • Proceed to surgery with beta-blocker therapy if not contraindicated 3
   • Optimize medical management of coronary disease 4
   • Standard perioperative cardiac monitoring 1

2. Moderately to severely reduced LV function (EF ≤35%) or extensive wall motion abnormalities:

   • Perform stress imaging to assess for inducible ischemia 3
   • If limited ischemia (1-4 segments): proceed with surgery on beta-blockers 3
   • If extensive ischemia (≥5 segments): consider cardiology consultation for possible revascularization before elective surgery 3

3. Severe symptomatic heart failure or unstable cardiac status:

   • Delay elective surgery until cardiac optimization 1

Important Caveats

The nonspecific T-wave abnormalities warrant careful interpretation 1. In the context of LVH and old infarct, these likely represent chronic changes rather than acute ischemia, but comparison with prior ECGs is essential 1, 5.

The sinus bradycardia of 55 is not concerning unless the patient has symptoms of bradycardia (lightheadedness, syncope, exercise intolerance) 2. If symptomatic bradycardia is present, 24-48 hour ambulatory monitoring should be considered 2.

Technical factors must be excluded: Ensure proper lead placement, as this can affect R-wave progression and voltage criteria 4, 5. The patient's body habitus and any prior chest surgeries can also affect ECG interpretation 5.

Perioperative Management Recommendations

Beta-blocker therapy should be initiated or continued perioperatively in this patient with known coronary disease undergoing intermediate-to-high risk surgery, as this reduces cardiac complications 3.

Postoperative troponin monitoring may be reasonable given the elevated baseline cardiac risk, though routine screening in all patients is not mandated 1.

The presence of LVH with voltage criteria alone (without repolarization abnormalities) carries lower risk than LVH with ST-T changes, which would be classified as a major abnormality 1.

Bottom Line for Clearance

Clearance should be conditional on:

1. Completion of echocardiogram within 1-2 weeks 2
2. Confirmation that old anterior infarct is stable (comparison with prior ECGs) 1
3. Assessment of current functional capacity and symptoms 1
4. Optimization of cardiac medications, particularly beta-blockers 3
5. Stress imaging if echocardiogram shows significant LV dysfunction or if patient has multiple cardiac risk factors 3

The surgery itself (laminectomy) is considered intermediate risk, and asymptomatic patients with stable chronic cardiac findings can generally proceed safely with appropriate perioperative management 1, 3.