Heart tests before surgery: When are they necessary?

If you’ve ever had surgery, you may recall having a preoperative evaluation, sometimes referred to as “clearance” for surgery. These check-ups often occur days or weeks prior to a planned, non-cardiac surgery and typically involve a physical exam. You also may get blood tests, x-rays, and an electrocardiogram (ECG) — a quick, painless test that records your heart’s electrical activity.

“These evaluations are designed to assess your chances of experiencing a heart-related problem during the surgery,” says Dr. Brendan Everett, director of the general cardiology inpatient service at Harvard-affiliated Brigham and Women’s Hospital. The term “clearance” is misleading, as there is no way to guarantee you won’t have complications. Still, knowing ahead of time about any heart-related risks you may have enables the surgeon to better prepare for possible complications and have a backup plan available, says Dr. Everett.

Share your symptoms

While the exam and test results are important, about 75% of the preoperative assessment is based on how you answer the doctor’s questions. “He or she needs to know how you feel when you exercise or climb stairs, because those details are important clues to your heart health and will guide the rest of the evaluation,” Dr. Everett explains. Around half of all surgeries are done in people ages 65 and older, many of whom take drugs to lower blood pressure or cholesterol. Many exercise regularly and feel perfectly fine. But others may feel short of breath on occasion, for example. Those people might need additional testing, Dr. Everett says.

Major vs. minor surgery

The nature of the surgery is also a big factor. Some major surgeries, such as a hip replacement, may lead to blood loss, altering the amount and location of fluid in the body. Anesthesia can cause changes in heart rate and blood pressure. All of these can tax the cardiovascular system, possibly uncovering previously undiagnosed heart disease. Other major surgeries include operations that open the skull, spine, chest, or abdomen and replacements of other large joints, such as the knee or shoulder.

Yet of the millions of surgeries done in the United States each year, about half are minor, low-risk procedures, such as those to treat cataracts or to 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 heart, and the risk of complications is usually minimal. So most people don’t need an ECG prior to these procedures—especially cataract surgery, which usually just takes 20 minutes and uses only local anesthesia. But between 10% and 25% of cataract surgery patients receive preoperative ECGs, according to Dr. Ishani Ganguli, assistant professor of medicine at Harvard Medical School.

Why is that a problem? Doctors can’t do much to lower the already low risk of cataract surgery. And although an ECG seems harmless, no test is perfect. An ECG can show false positives — that is, the results suggest something abnormal that truly isn’t, says Dr. Ganguli. If the ECG seems abnormal, the doctor then may order more tests — such as an exercise stress test, which monitors your heart with an ECG or echocardiography (heart ultrasound) 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, says Dr. Ganguli. In fact, the American College of Cardiology discourages ECGs in people slated for low-risk surgery, provided they don’t have any symptoms.

If you’re slated for surgery, you’ll have a pre-surgical evaluation with a health care provider. Be sure to bring the following to your appointment:a list of all the medications you take, including over-the-counter drugs, vitamins, and other dietary supplementsany imaging or testing results done at other facilitiescontact information for your primary care provider and cardiologist, if you have one.

What you can do

To help avoid unnecessary preoperative tests, you can ask doctors if and how the results of any tests they recommend will change your treatment. “It doesn’t have to be confrontational; you could ask ‘Can you help me understand why I need this test?'” says Dr. Ganguli. To help ensure you are getting tests that you truly do need, always be straightforward and clear about any symptoms you have, says Dr. Everett.

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1 Chronicles 6:31-32 Now these are those whom David appointed over the service of song in the house of the LORD, after the ark rested there. They ministered with song before the tabernacle of the tent of meeting, until Solomon had built the house of the LORD in Jerusalem; and they served in their office according to their order.

1 Chronicles 25:1 Moreover, David and the commanders of the army set apart for the service some of the sons of Asaph and of Heman and of Jeduthun, who were to prophesy with lyres, harps and cymbals; and the number of those who performed their service was:

2 Chronicles 35:15 The singers, the sons of Asaph, were also at their stations according to the command of David, Asaph, Heman, and Jeduthun the king’s seer; and the gatekeepers at each gate did not have to depart from their service, because the Levites their brethren prepared for them.

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