Electrocardiogram Guidelines

Indications for Electrocardiogram

• The American College of Cardiology recommends performing an electrocardiogram (EKG) in patients with cardiac symptoms, including chest pain, syncope, near-syncope, palpitations, unexplained dyspnea, or extreme fatigue, as well as for patients with known cardiovascular disease who have changes in symptoms or are undergoing preoperative evaluation 1, 2
• The American College of Cardiology recommends acquiring and reviewing an ECG within 10 minutes of arrival for patients with acute chest pain in the office setting 2
• The American Heart Association recommends ECGs for patients with known cardiovascular disease when there are changes in symptoms, signs, or relevant laboratory findings 1
• The American College of Cardiology suggests serial ECGs when the initial ECG is nondiagnostic but clinical suspicion remains high for acute coronary syndrome (ACS) 2

Preoperative Evaluation

• The American College of Cardiology recommends preoperative ECGs for all patients with known cardiovascular disease or dysfunction before cardiac or non-cardiac surgery 1
• The American College of Cardiology suggests that patients with hemodynamically insignificant heart disease or minimal hypertension may have less urgent need for preoperative ECG 1
• The following patient populations are recommended for ECG testing:

3, 4, 2, 5, 1, 6

Risk Assessment and Follow-up

• The American College of Cardiology recommends periodic follow-up ECGs (every 1-5 years) for patients at increased risk for developing cardiac disease 1
• The American Heart Association recommends ECGs for patients with laboratory findings suggesting cardiac disease or dysfunction 1
• The American College of Cardiology recommends selecting monitoring based on symptom frequency, including 24-hour Holter monitor, event or wearable loop recorder, and implantable loop recorder, for patients with suspected arrhythmias 7, 8

Diagnostic Testing

• Echocardiography is indicated when there is an abnormal cardiac examination, ECG abnormalities, history suggesting structural heart disease, or symptoms occurring with exertion, as recommended by the American College of Cardiology 9
• Exercise stress testing should be considered when dizziness is associated with exertion or suspected ischemic heart disease, according to the American College of Cardiology 9
• Tilt-table testing is useful when suspected vasovagal syncope or orthostatic hypotension not detected with standard orthostatic measurements, as suggested by the European Heart Society 6

Management of Cardiac Conditions

• The European Society of Cardiology recommends considering RAAS blockade with ACE inhibitors or ARBs in patients with left ventricular hypertrophy (LVH) 10
• For unstable patients with sustained ventricular tachycardia, the European Society of Cardiology recommends immediate synchronized direct current cardioversion, starting with maximum output if cardiac arrest is suspected, and providing appropriate sedation if the patient is conscious 11
• For supraventricular tachycardia (SVT), the European Society of Cardiology recommends an initial approach of vagal maneuvers or intravenous adenosine, with IV diltiazem, verapamil, or beta-blockers for rate control if unsuccessful 10
• For atrial fibrillation, the European Society of Cardiology recommends assessing stroke risk using the CHA₂DS₂-VASc score, considering anticoagulation for those with a score ≥1 in males, ≥2 in females, and aiming for rate control with a heart rate <110 bpm initially 10

ECG Interpretation

• Normal ECG values include heart rate (60-100 bpm), PR interval (120-200 ms), QRS duration (<120 ms), and QT/QTc interval (<440 ms in men, <460 ms in women), according to the American Heart Association 1, 12
• Left ventricular hypertrophy criteria include Sokolow-Lyon, Cornell voltage, and Romhilt-Estes point score systems, while right ventricular hypertrophy and atrial enlargement criteria are also essential for ECG interpretation, as stated by the American College of Cardiology and American Heart Association 12, 1
• Age-specific and athlete-specific criteria should be applied for accurate ECG interpretation, as recommended by the American Heart Association and American College of Cardiology 12, 13

Avoiding Common Pitfalls

• The American College of Cardiology advises against initiating Class I or III antiarrhythmic drugs without documented arrhythmia 7
• The European Society of Cardiology recommends not overlooking modifiable risk factors for bleeding in patients requiring anticoagulation 10
• The European Heart Society and American College of Cardiology recommend against relying solely on a single normal ECG to rule out cardiac causes, failing to obtain appropriate rhythm monitoring when arrhythmia is suspected, and not performing orthostatic vital signs in all patients with dizziness 6, 1