Approach to preoperative electrocardiographic findings

ECG finding	Associated conditions of concern	Management
Findings that may warrant further evaluation and management (including possible delay or cancellation of elective surgery)
Acute or new axis deviation or ventricular overload pattern	Acute chamber strain (pulmonary emboli), acute pneumothorax	Exclude lead misplacement Evaluate and manage cause
Acute or new ST-segment elevation in ≥2 contiguous leads^*	Acute ST-elevation myocardial infarction or acute pericarditis	Evaluate and manage cause Consider other causes; ST-elevation is usually localized with myocardial infarction and diffuse with pericarditis
Acute or new ST-segment depression in multiple leads	Myocardial ischemia	Evaluate and manage cause
Tall peaked T waves	Hyperkalemia or hyperacute phase of acute myocardial infarction	Evaluate and manage myocardial infarction Evaluate and manage hyperkalemia
Acute deep symmetric T wave inversions	Acute myocardial ischemia or infarction	Evaluation and manage myocardial infarction
Acute or new pathologic Q waves	Myocardial infarction, cardiomyopathy, myocarditis	Evaluate and manage cause
Type II second degree atrioventricular (AV) block or third degree AV block	Conduction system disease Type II second degree AV block may progress to complete heart block	Evaluate hemodynamic status If unstable, treat with a beta-adrenergic agonist agent and temporary cardiac pacing If stable, monitor continuously with transcutaneous pacing pads in place Evaluate and manage cause
Acute or new BBB	Acute myocardial ischemia or infarction, myocarditis RBBB occurs in some with acute pulmonary embolus	Evaluate and manage cause
Narrow complex supraventricular tachyarrhythmias (SVTs)	Causes include AVNRT, AVRT, atrial fibrillation, atrial flutter, and atrial tachycardia	Evaluate the arrhythmia and treat according to cause
Non- sustained ventricular tachycardia (NSVT)	Precipitants include hypoxia, electrolyte abnormalities, myocardial ischemia, and heart failure	Determine if NSVT is new Evaluate and manage cause
QT prolongation	Prolonged QTc is caused by acquired (eg, medications, hypokalemia, hypomagnesemia, hypocalcemia) or congenital syndromes	Determine if the QTc is prolonged Evaluate and manage cause
Findings that may alter anesthetic management
Left ventricular hypertrophy	Chronic hypertension, aortic stenosis, hypertrophic cardiomyopathy	Minimize hypovolemia, hypotension, and tachycardia
Sinus bradycardia at a heart rate <40 bpm, first degree AV block, or Type I second degree AV block	Increased vagal tone, concomitant use of AV nodal blocking agents, AV nodal disease	Avoid procedures or maneuvers or agents that increase vagal tone Vagolytic and chronotropic agents should be immediately available to treat severe bradycardia
Wolff-Parkinson-White (WPW) syndrome	Risk of rapid ventricular activation and degeneration to ventricular fibrillation if there is atrial fibrillation with rapid conduction along the accessory pathway	Consult with cardiologist Minimize adrenergic stimulation Avoid AV nodal blocking agents in setting of antidromic atrioventricular reciprocating tachycardia or atrial fibrillation with preexcitation
Sinus tachycardia	Hypovolemia, anemia, heart failure, infection, anxiety	Evaluate and treat cause
Frequent PVCs	Triggers include hypoxia, uncontrolled hypertension, electrolyte abnormalities, myocardial ischemia, and heart failure	Evaluate and treat triggers
Findings that rarely alter anesthetic management
Occasional PVCs	Variety of medical and cardiac conditions such as electrolyte abnormalities, valvular heart disease, heart failure, cardiomyopathy	Compare with prior ECGs Assess for history of cardiac disease Correct electrolyte abnormalities
Chronic ST depressions or T wave flattening or inversion	CAD, valvular heart disease (aortic stenosis, mitral regurgitation), hypertension, cardiomyopathy	Compare with prior ECGs Assess for history of cardiac disease

AVNRT: atrioventricular nodal reentrant tachycardia; AVRT: atrioventricular reentrant tachycardia; BBB: bundle branch block; CAD: coronary artery disease; ECG: electrocardiogram; PVC: premature ventricular contractions; QTc: Heart rate-corrected QT interval.

* The joint European Society of Cardiology, American College of Cardiology Foundation, the American Heart Association, and the World Heart Federation (ESC/ACCF/AHA/WHF) committee for the definition of MI established the following ECG criteria for the diagnosis of ST-elevation MI:

New ST-segment elevation at the J-point in two contiguous leads, with the cut-points ≥0.1 mV in all leads other than leads V2 to V3.
For leads V2 to V3: ≥2 mm in men ≥40 years; ≥2.5 mm in men <40 years, or ≥1.5 mm in women regardless of age.

Reference:

Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018; 72:2231.

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Approach to preoperative electrocardiographic findings