American College of Cardiology

View all recommendations from this society

Updated January 11, 2021

Avoid performing electrocardiography (ECG) screening as part of preoperative cardiovascular risk assessment in asymptomatic patients scheduled for low-risk non-cardiac surgery.

Despite potential value in having a pre-operative ECG to identify unsuspected cardiac abnormalities or as a comparison after a perioperative event, the likelihood of benefit for patients at low (<1%) risk of major cardiovascular events (death or myocardial infarction) is very small. Unnecessary ECGs can lead to needless consults, delays and changes to operative plans, which may counterbalance any potential benefit for the patient. In the absence of scientific studies establishing the value of a pre-operative ECG in a low cardiovascular risk population, the routine ordering of pre-operative ECGs prior to low-risk procedures should be discouraged.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American College of Cardiology (ACC) asked its standing clinical councils to recommend between three and five procedures that should not be performed
or should be performed more rarely and only in specific circumstances. ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that were either Rarely Appropriate AUC recommendations or Class III guideline recommendations. The ACC’s Science and Quality Committee then reviewed and approved the final five items. ACC’s disclosure and conflict of interest policy can be found at


Fleisher LA, Fleischmann KE, Auerback AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman M, Holly TA, Kane GC, Marine JE, Nelson T, Spencer CC, Thompson, A, Ting HH, Uretsky B, Wiievsundera D. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journ Am Coll Cardiol. 2014 December;64(22);77-137.

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