What are the indications for obtaining a preoperative echocardiogram?

Preoperative Echocardiography Indications

Preoperative echocardiography is indicated only when patients have new or worsening cardiac symptoms, suspected significant valvular disease, or known heart failure with clinical status changes—routine screening in asymptomatic, stable patients provides no benefit and should not be performed. 1

Class I Indications (Strongly Recommended)

Obtain preoperative echocardiography in these specific scenarios:

• New dyspnea with suspected cardiac etiology – Patients presenting with new-onset dyspnea, physical examination findings of heart failure, or suspected new/worsening ventricular dysfunction require echocardiographic evaluation to guide perioperative management 1

• Suspected significant valvular disease – When clinical examination reveals murmurs suggesting moderate or severe valvular stenosis or regurgitation, particularly if no echocardiogram has been performed within the past year 2, 3

• Known heart failure with clinical deterioration – Patients with established heart failure diagnosis who develop worsening dyspnea or other changes in clinical status warrant reassessment of left ventricular function 1

• Hemodynamic instability of cardiac origin – Any patient with unexplained hypotension, cardiogenic shock, or cardiac arrest requires immediate echocardiography to identify the underlying cause 2

Class IIa Indications (Reasonable to Perform)

Consider preoperative echocardiography when:

• Known heart failure without recent assessment – Patients with diagnosed heart failure undergoing noncardiac surgery may benefit from functional assessment if clinical status is uncertain, though this is reasonable rather than mandatory 1

• Suspected aortic stenosis based on clinical criteria – When two or more of the following are present: angina on exertion, unexplained syncope, slow-rising pulse, absent second heart sound, or left ventricular hypertrophy on ECG without hypertension 3

Class III Indications (Not Recommended—No Benefit)

Do NOT order preoperative echocardiography in these situations:

• Asymptomatic, clinically stable patients – Routine preoperative evaluation of left ventricular function in patients without symptoms or clinical signs of cardiac disease is not recommended due to lack of benefit 1

• Low-risk surgical procedures in asymptomatic patients – Even in patients with known cardiovascular disease, if they are asymptomatic and undergoing low-risk surgery, echocardiography does not improve outcomes 4

• Based on anesthesia type alone – The decision for echocardiography should be driven by clinical findings suggesting structural heart disease, not by whether the patient will receive IV sedation versus general anesthesia 3

Evidence Quality and Nuances

The 2024 ACC/AHA guidelines provide the most current framework, emphasizing that abnormal left ventricular function (both systolic and diastolic) is associated with increased perioperative major adverse cardiac events (MACE), particularly with lower ejection fractions, higher surgical risk procedures, and additional comorbidities 1. However, the incremental benefit of preoperative echocardiography was observed only in higher-risk patients, not in routine screening 1.

A critical study of 570 patients demonstrated that risk models including echocardiographic elements performed better than clinical variables alone (c statistic 0.73 vs 0.68), but this advantage disappeared in lower-risk populations 1. Retrospective data from 2,976 patients showed that grade 3 diastolic dysfunction increased perioperative MACE risk, but grades 1-2 did not 1.

Important caveat: Research from the Veterans Affairs system involving 26,641 surgeries found that preoperative echocardiography was not associated with lower risk of postoperative MACE, even in high-risk populations with recent myocardial infarction, valvular disease, or heart failure (odds ratio 1.8-1.9 for MACE) 5. This suggests that while echocardiography identifies risk, it does not necessarily translate into effective changes in care that improve outcomes.

Clinical Decision Algorithm

Step 1: Assess symptom status

• If new dyspnea, worsening heart failure symptoms, or suspected cardiac decompensation → Order echocardiography 1
• If asymptomatic and stable → Proceed to Step 2

Step 2: Evaluate for valvular disease

• If murmur suggesting moderate/severe stenosis or regurgitation → Order echocardiography 2, 3
• If no significant murmur → Proceed to Step 3

Step 3: Consider surgical risk and cardiac history

• If known heart failure with uncertain functional status and high-risk surgery → Consider echocardiography 1
• If asymptomatic with stable cardiac disease or low/intermediate-risk surgery → No echocardiography indicated 1, 4

Common Pitfalls to Avoid

• Ordering "routine" preoperative echocardiograms – This practice wastes resources and does not improve outcomes in asymptomatic patients 1, 4

• Using echocardiography as a substitute for clinical examination – The basic cardiovascular evaluation remains the most appropriate screening method 1, 2

• Delaying surgery to obtain unnecessary echocardiography – Using "awaiting echocardiography" as a reason to delay necessary surgery in stable patients is unacceptable 3

• Assuming echocardiography will change management – Even when abnormalities are identified, evidence suggests this rarely translates into interventions that reduce perioperative MACE 5