Upcoming surgery? You may not need any heart tests beforehand
Even in people with heart disease, presurgical cardiac testing should be the exception, not the rule.
- Reviewed by Christopher P. Cannon, MD, Editor in Chief, Harvard Heart Letter; Editorial Advisory Board Member, Harvard Health Publishing
If you've ever had surgery, you may recall having a preoperative evaluation, sometimes referred to as "clearance" for surgery. These check-ups take place prior to a planned noncardiac surgery and typically include a physical exam and a detailed medical history. You may also get blood tests and x-rays. And you might have an electrocardiogram (ECG), a quick, painless test that records your heart's electrical activity. But what's the real purpose of a presurgical ECG — and when does getting this test actually make sense?
"For the vast majority of people, even those with known heart disease, an ECG isn't helpful before most surgeries," says Dr. Christian Ruff, director of general cardiology at Harvard-affiliated Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School. The purpose of a preoperative evaluation is to assess whether a person might be at elevated risk of a heart-related complication during or after surgery, he explains. However, an ECG (which lasts only about 30 seconds) isn't necessarily the best way to gauge a person's risk. And sometimes, the findings end up delaying a person's surgery for no good reason if they trigger unnecessary additional testing.
Minor vs. major surgery
About half of the millions of surgeries done in the United States each year are minor procedures, such as those to treat cataracts or repair damaged tendons or joints. Often referred to as "same-day," outpatient, or ambulatory surgery, they do not require a hospital stay. Other examples include a breast biopsy or hernia repair. These low-risk procedures put very little strain on the cardiovascular system, and the risk of complications is minimal. Still, an estimated one in 10 cataract surgery patients receive preoperative ECGs, despite the fact that the American College of Cardiology discourages ECGs in people slated for low-risk surgeries, provided they don't have any symptoms.
Of course, major surgeries pose a somewhat greater risk to the heart. Surgeries that open the skull, spine, chest, or abdomen may lead to blood loss and fluid shifts in the body, which can put extra stress on the heart. So does anesthesia, which can cause changes in heart rate and blood pressure. Still, ECGs aren't routinely needed even before major surgery, says Dr. Ruff. Instead, asking about how people feel when they're active is more important. "If a person can walk up one or two flights of stairs without any significant symptoms such as chest discomfort or breathlessness, they're at very low risk of cardiac complications during surgery," he says. However, ECGs do make sense for older, inactive people with heart disease prior to major surgery. "We want to make sure they're not having any signs of reduced blood flow to the heart or an unstable electrical heart rhythm that may require treatment before they undergo surgery," says Dr. Ruff.
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If you're slated for surgery, bring the following to your preoperative evaluation:
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Other surgery-related concerns
People who have recently experienced a heart attack or pulmonary embolism or who have received an artery-opening stent will likely need to delay any elective (that is, non-emergency) surgeries for a few months. (Elective surgery itself isn't always a choice, but to some extent, you can elect when to have it.) In addition, many people with heart conditions, such as atrial fibrillation or deep-vein thrombosis, take medications to prevent blood clots. Because these drugs can increase bleeding risk, they should be stopped two to three days before surgery.
Take-home message
Why are routine preoperative ECGs a problem? If the results are abnormal, the doctor then may order more tests — such as an exercise stress test, which monitors your heart while you exercise on a treadmill. But again, the findings are sometimes inconclusive, leading to yet another test. This "cascade" of testing often ends up doing more harm than good because of the added cost, time, and stress it causes patients — not to mention potentially postponing a surgical procedure that can improve a person's quality of life.
"If your health care provider says you need an ECG or another test, ask 'What are you looking for, and will the results change how you will treat me with respect to the procedure?'" says Dr. Ruff.
Image: © supersizer/Getty Images
About the Author
Julie Corliss, Executive Editor, Harvard Heart Letter
About the Reviewer
Christopher P. Cannon, MD, Editor in Chief, Harvard Heart Letter; Editorial Advisory Board Member, Harvard Health Publishing
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