Does an elderly female patient with a history of cardiac disease or significant cardiac risk factors, such as hypertension or diabetes, require an electrocardiogram (ECG) before undergoing hernia repair?

Preoperative ECG for Elderly Female Before Hernia Repair

Yes, an elderly female patient requires a preoperative ECG before hernia repair, particularly if she is over 65 years of age or has cardiovascular risk factors such as hypertension or diabetes. 1

Age-Based Recommendation

• All patients over 40 years old should have a preoperative ECG, even without suspected cardiac disease. 2, 3
• Patients older than 65 years require preoperative ECG regardless of other risk factors. 1
• The American Heart Association established this as a Class I indication (strongest recommendation level) for patients >40 years undergoing surgery. 2

Risk Stratification for Hernia Repair

Hernia repair typically qualifies as intermediate-risk surgery requiring the following approach:

• Patients with known cardiovascular disease, hypertension, or diabetes undergoing intermediate-risk surgery should have a preoperative EKG. 1
• Even patients with at least one clinical risk factor (such as hypertension or diabetes) undergoing intermediate-risk procedures should receive preoperative EKG. 1
• The ECG serves to establish baseline cardiac status and guide perioperative management, particularly important given age-related cardiovascular changes. 1

Clinical Risk Factors That Mandate ECG

The following factors in your elderly female patient would strengthen the indication:

• History of ischemic heart disease 1
• History of compensated or prior heart failure 1
• Hypertension 1
• Diabetes mellitus 1
• Peripheral vascular disease or cerebrovascular disease 1

Evidence Quality Considerations

While one older study from 2002 suggested that preoperative ECG abnormalities did not predict postoperative cardiac complications in geriatric patients 4, this finding should not override current guideline recommendations. The guidelines prioritize ECG for:

• Establishing baseline cardiac status 1
• Guiding perioperative management decisions 1
• Informing anesthetic selection (e.g., QT prolongation may affect choice of anesthetics or antiemetics) 1

More recent evidence from 2024 demonstrates that 48.78% of older surgical patients had abnormal preoperative ECGs, with 44.16% classified as major abnormalities. 5 The most common findings were left axis deviation, left ventricular hypertrophy, and ST segment changes. 5

Timing of the ECG

• Obtain the 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
• If new cardiac symptoms develop (syncope, new dyspnea, change in angina pattern, palpitations, extreme fatigue), obtain ECG on day of surgery. 1

Common Pitfalls to Avoid

• Do not skip the ECG based solely on absence of symptoms – elderly patients frequently have silent cardiac disease, and age >65 years alone is sufficient indication. 1
• Always compare with previous ECGs when available – chronic findings should not be misinterpreted as acute changes. 1, 6
• Do not order ECG "routinely" without understanding its purpose – the ECG is indicated here based on age and risk factors, not as a blanket screening test. 1

What to Do With Abnormal Findings

If the preoperative ECG shows abnormalities:

• New 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 should be further evaluated to refine cardiovascular risk assessment. 1
• T wave abnormalities suggesting lateral ischemia warrant further cardiac evaluation before proceeding with surgery. 1, 6
• Active cardiac conditions (decompensated heart failure, significant arrhythmias) require evaluation and treatment before proceeding. 1