Preoperative EKG Evaluation for Noncardiac Surgery

Active Cardiac Conditions Requiring Delay of Surgery

The American College of Cardiology recommends that surgery be postponed if the EKG reveals unstable or severe arrhythmias, such as symptomatic ventricular arrhythmias, high-grade AV block, symptomatic bradycardia, or newly recognized ventricular tachycardia, in patients undergoing noncardiac surgery 1, 2
The American College of Cardiology also recommends that patients with acute decompensated heart failure, if clinical correlation supports this, require immediate cardiology evaluation and treatment before proceeding with elective noncardiac surgery 1, 2
Patients with these active cardiac conditions require immediate cardiology evaluation and treatment per ACC/AHA guidelines before proceeding with elective noncardiac surgery 3, 4

The American College of Cardiology states that chronic Q waves, indicating old myocardial infarction, without symptoms do not automatically delay surgery, but warrant echocardiography to assess left ventricular function 5
Asymptomatic patients with bundle branch blocks, left ventricular hypertrophy with strain pattern, or nonspecific ST-T wave changes without acute ischemic pattern do not require delay of surgery 2
Isolated premature ventricular contractions or asymptomatic nonsustained ventricular tachycardia also do not require delay of surgery 2

For low-risk surgery, the American College of Cardiology recommends proceeding regardless of EKG findings in asymptomatic patients 1, 2, 6
Routine preoperative EKG is Class III, not recommended, for low-risk procedures 7, 6
For intermediate-risk surgery, patients with excellent functional capacity and no symptoms can proceed with surgery despite EKG abnormalities 7
Patients with poor functional capacity and 1-2 clinical risk factors should consider noninvasive stress testing only if it will change management, which is a Class IIb recommendation 3, 4
For high-risk or vascular surgery, patients with ≥3 clinical risk factors and poor functional capacity should undergo noninvasive stress testing if it will change management, which is a Class IIa recommendation 3, 4

Ordering routine EKGs without clinical indication increases costs without improving outcomes 7
Failing to assess functional capacity is a pitfall, as functional capacity is more predictive than EKG findings 7
Not comparing with previous EKGs can lead to misinterpretation of chronic findings as acute, which may unnecessarily delay surgery 7

Consult cardiology before proceeding if there are new pathological Q waves with unknown cardiac history, which requires echocardiography to assess left ventricular function 5
High-grade conduction abnormalities, such as Mobitz type II or complete heart block, require cardiology consultation 7
A prolonged QT interval that may affect anesthetic selection also requires cardiology consultation 7