Prior to surgical procedures, patients undergo a preoperative evaluation to determine surgical suitability and identify risk factors that may increase the likelihood of perioperative complications. One commonly utilized component of this evaluation is the electrocardiogram (ECG), which helps detect cardiac arrythmias, structural abnormalities, or evidence of ischemia that may predispose patients to major adverse cardiac events (MACE) during or after surgery. Historically, preoperative ECGs were frequently ordered for broad patient populations, particularly older adult. However, evolving evidence has demonstrated that selective preoperative ECG screening based on clear indications and individualized evaluation is more clinically effective and cost-efficient than routine universal testing.
Earlier preoperative screening practices supported liberal ECG ordering for both minor and major surgical procedures, especially among elderly patients. This approach was largely justified by the significant morbidity and mortality associated with perioperative cardiac complications and by ability of ECGs to identify occult cardiovascular disease. A study involving more than 23,000 patients undergoing noncardiac surgery found that patients with ECG abnormalities had a 4.5-fold increased risk of cardiovascular mortality compared with patients who had normal ECG findings (Noordzij et al., 2006). However, the study also demonstrated that the prognostic value of ECG abnormalities was substantially less significant in low- and intermediate-risk surgical procedures. Similarly, a cohort study of approximately 3,000 surgical patients reported that although preoperative ECG abnormalities were associated with postoperative cardiac complications, ECG findings provided little additional predictive value beyond information obtained through standard clinical history and physical examination (van Klei et al., 2007).
As evidence accumulated, contemporary guidelines shifted toward a more selective approach to preoperative ECG testing. The 2024 American Heart Association (AHA) guidelines stratify perioperative cardiovascular risk into low-risk (<1% risk of MACE) and elevated-risk (≥1% risk of MACE) categories. According to these guidelines, asymptomatic patients undergoing low-risk surgical procedures generally do not require a preoperative ECG regardless of age because the likelihood of perioperative cardiac complications is minimal.
For patients undergoing intermediate- or high-risk procedures, such as major vascular or thoracic surgery, the guidelines recommend a stepwise assessment that incorporates functional capacity, commonly measured in metabolic equivalents (METs). Patients with functional capacity of at least 4 METs, such as the ability to climb two flights of stairs without symptoms, are considered to have adequate exercise tolerance and often do not benefit from routine ECG screening. In contrast, known cardiovascular disease, new cardiac symptoms, significant cardiovascular risk factors, or poor functional capacity remain indications for preoperative ECG screening in patients who are undergoing elevated-risk surgery.
Overall, the role of the preoperative ECG has evolved from a strategy of routine universal screening to one centered on individualized risk stratification. Although ECGs remain valuable in high-risk populations, modern evidence-based guidelines increasingly emphasize clinical history, physical examination, and surgical risk assessment over indiscriminate testing. In addition, reducing unnecessary preoperative ECG testing helps limit false-positive findings that may lead to further invasive testing, specialist consultations, or delays in surgical scheduling. Selective screening protocols therefore improve healthcare efficiency while reducing patient anxiety and avoiding interventions unlikely to improve perioperative outcomes or overall patient safety.
References
- Dobson GP. Trauma of major surgery: A global problem that is not going away. Int J Surg. 2020;81:47-54. doi:10.1016/j.ijsu.2020.07.017
- Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol. 2006;97(7):1103-1106. doi:10.1016/j.amjcard.2005.10.058
- van Klei WA, Bryson GL, Yang H, et al. The value of routine preoperative electrocardiography in predicting myocardial infarction after noncardiac surgery. Ann Surg. 2007;246(2):165 170. doi:10.1097/01.sla.0000261737.62514.63
- Thompson A, Fleischmann KE, Smilowitz NR, de las Fuentes L, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;150(22). doi:10.1161/CIR.0000000000001285