Preoperative cardiac evaluation in elective non-cardiac surgery in India: Routine ECG, echocardiography, and angiography are not mandatory.

BACKGROUND

Preoperative cardiac testing aims to identify patients at risk of perioperative cardiovascular complications, but indiscriminate use of tests like electrocardiograms (ECGs), echocardiography (ECHO), and even coronary angiography in low-risk patients often provides little benefit. International guidelines (2024 American College of Cardiology/American Heart Association and 2022 European Society of Cardiology) now emphasize a selective, risk-based approach rather than routine screening. In India, clinicians face pressure - including medicolegal concerns - to order extensive preoperative investigations. This article provides an evidence-based framework, from an Indian perspective, to guide when preoperative ECG, transthoracic echocardiography (TTE), or angiographic evaluation are truly warranted for elective non-cardiac surgeries, strongly emphasizing that these tests are in every case.

METHODS

A narrative review was conducted, synthesizing recommendations from the 2024 ACC/AHA Guideline for perioperative cardiovascular evaluation and the 2022 ESC Guideline on non-cardiac surgery, along with key studies and Indian practice insights. We focused on guideline-directed indications for preoperative ECG and ECHO, highlighting Class III recommendations (tests not recommended) versus scenarios where testing is appropriate. Evidence from randomized trials (e.g., CARP trial) and observational cohorts was reviewed to assess outcome impact of routine testing. Consideration was given to India-specific factors such as higher prevalence of cardiovascular disease and defensive medical practices. The findings were distilled into a decision algorithm and summary tables stratified by surgical risk and patient factors.

RESULTS

Routine preoperative ECG or ECHO in asymptomatic patients undergoing low-risk surgery (expected <1 % 30-day Major Adverse Cardiac event risk) is not recommended (Class III, no benefit). The 2022 ESC guidelines do not recommend ECG even for intermediate risk surgeries in those who are asymptomatic and do not have pre existing heart disease (Class III). Unnecessary testing in low-risk situations did not improve outcomes and can lead to delays. For intermediate- or high-risk surgeries, a baseline ECG is reasonable, especially in patients with known cardiovascular disease (ACC/AHA Class IIa; ESC Class I). However, even for intermediate risk surgeries, an ECG is if the patient is asymptomatic and has good functional capacity and has no pre existing heart disease, aligning with 2024 ACC AHA and 2022 ESC guidance (Class III for low-risk patients) and a judicious approach. Preoperative TTE is indicated (Class I) for patients with active cardiac symptoms - for example, new or worsening heart failure signs, or a murmur suggestive of significant valvular disease. Patients with known cardiac dysfunction should have TTE only if there is a change in clinical status or if no recent assessment is available (Class IIa). In patients with poor or unknown functional capacity (<4 METs [metabolic equivalents]) facing high-risk surgery, further cardiac evaluation is warranted: Importantly, in the absence of symptoms or clinical risk factors, neither ECHO nor stress testing should be done routinely. Routine coronary angiography or CT angiography is not indicated as a screening tool in asymptomatic patients - it is reserved for those with high-risk findings or active cardiac conditions (Class III for routine use). We developed a stepwise algorithm to guide selective testing, which can be integrated into hospital standard operating procedures (SOPs).

CONCLUSION

Not all patients require extensive cardiac work-up before surgery. An evidence-based, selective strategy can safely optimize care: preoperative ECG and ECHO are performed only when clinical indicators suggest necessity, rather than as routine for every case. This approach is supported by current guidelines and outcome studies and maximizes patient safety and resource utilization. In the Indian medicolegal context, adhering to such guideline-driven protocols establishes a clear standard of care, protecting clinicians who avoid unnecessary tests. By documenting rationale for selective testing (or omission of testing) per accepted guidelines, doctors can shield themselves from medicolegal accusations, while focusing on truly at-risk patients. Ultimately, a targeted preoperative cardiac evaluation strategy ensures high-value care - doing the right test for the right patient - and prevents over-testing that is not mandatory for low-risk scenarios.