When is an EKG Required During Physical Examinations?
An EKG is required during preoperative physical examinations for patients with known cardiovascular disease undergoing any surgery, and should be obtained during preparticipation sports physicals for masters athletes (men >40-45 years or women >50-55 years) with cardiac risk factors who plan to engage in vigorous competitive activities. 1
Preoperative Physical Examinations
A recent preoperative ECG is strongly recommended (Class I indication) for all patients with known cardiovascular disease or dysfunction undergoing cardiac or noncardiac surgery, as these patients face increased risk for perioperative cardiovascular complications. 1
Patients with hemodynamically insignificant congenital or acquired heart disease, minimal to mild systemic arterial hypertension, or infrequent premature complexes without organic heart disease receive a Class II recommendation (may be considered but not mandatory). 1
The preoperative ECG should be recent and interpreted by a qualified physician as part of the medical record. 1
Sports Preparticipation Physical Examinations
Masters athletes require ECG exercise testing during their preparticipation physical if they have a moderate-to-high cardiovascular risk profile and desire to enter vigorous competitive situations. 1
Specific criteria requiring ECG exercise testing include:
Men aged 40-45 years or older, or women aged 50-55 years or older (or postmenopausal) with one or more coronary risk factors. 1
Risk factors include: hypercholesterolemia (total cholesterol >200 mg/dL, LDL >130 mg/dL, HDL <35 mg/dL for men or <45 mg/dL for women), systemic hypertension (systolic BP >140 mmHg or diastolic >90 mmHg), current or recent cigarette smoking, diabetes mellitus, or family history of myocardial infarction or sudden cardiac death in a first-degree relative <60 years old. 1
Athletes of any age with symptoms suggestive of coronary disease require ECG exercise testing. 1
Athletes ≥65 years old require ECG exercise testing even without risk factors or symptoms. 1
Standard preparticipation screening components:
A 12-lead resting ECG should be obtained along with personal and family cardiac history and physical examination focusing on detecting previously undiagnosed coronary artery disease. 1
The history must specifically assess for premature sudden death in the family, heart disease in surviving relatives, heart murmurs, femoral pulses, stigmata of Marfan syndrome, and blood pressure measurement. 1
Physical Examinations for Patients with Suspected Cardiac Disease
An ECG is integral to the initial evaluation when cardiovascular disease is suspected based on symptoms, abnormal physical findings, previous abnormal ECGs, or abnormal radiographic/echocardiographic findings. 1
Symptoms warranting ECG during physical examination:
- Syncope and near-syncope 1
- Unexplained change in usual pattern of angina pectoris pain 1
- New or worsening dyspnea 1
- Extreme and unexplained fatigue, weakness, and prostration 1
- Palpitations 1
Physical examination findings requiring ECG:
- Congestive heart failure signs (elevated jugular venous pressure, third heart sound, laterally displaced apical impulse) indicate higher risk of adverse outcomes and warrant ECG. 1
- Cardiac murmurs consistent with valvular disease or outflow obstruction require ECG evaluation. 1
Routine Physical Examinations Without Cardiac Indications
Routine ECG screening is NOT recommended for asymptomatic adults without known or suspected cardiovascular disease during general physical examinations. 1
The U.S. Preventive Services Task Force gives a Class III recommendation (not recommended) for screening with ECG in asymptomatic persons without known coronary artery disease. 1
ECG screening in older people from the general population does not provide additional prognostic information beyond accurate medical records when no cardiac symptoms or disease are present. 2
Routine ECG is not recommended as part of periodic health examinations in asymptomatic children or adults by the American Academy of Family Physicians. 1
Common Pitfalls to Avoid
Do not order routine ECGs during annual physical examinations for asymptomatic patients without cardiac risk factors, as this leads to false-positive results and unnecessary downstream testing. 1, 2
Ensure ECGs are interpreted by a qualified physician rather than relying solely on computer interpretation, as computer-only readings are not recognized as properly interpreted ECGs. 1
Always compare current ECG tracings with previous tracings when available to detect interval changes. 3
Remember that a completely normal ECG makes heart failure very unlikely (<2% likelihood in acute presentations, <10-14% in non-acute presentations). 1