European Journal of Cardiovascular Medicine

Cataract surgery is among the most frequently performed surgical procedures worldwide, particularly in the elderly population who often present with multiple comorbidities, including cardiovascular disease. Preoperative workup practices vary widely around the world. Guidelines given by various medical bodies may not cover these variations. Cataract surgery is mostly an elective surgery and perioperative morbidity and mortality in general is un acceptable to public. Careful evaluation of all patients is mandatory. There is a tendency in general population that few patients intentionally do not disclose their medical condition due to fear of postponement/cancellation of cataract surgery.

As violence against doctors and legal implications through consumer courts are steadily increasing Ophthalmologists must be more watchful. Preoperative electrocardiogram (ECG) monitoring plays a pivotal role in detecting underlying cardiac conditions and identifying potentially hazardous rhythm or conduction abnormalities that may arise during surgery. Given that most cataract surgeries are performed under local anaesthesia with sedation, patients may still experience stress-induced hemodynamic fluctuations, electrolyte imbalances, or ischemic changes reflected in their ECG patterns. Recognizing and interpreting operative ECG patterns—such as arrhythmias, ischemic changes, conduction blocks, or repolarization abnormalities—are critical for anaesthesiologists and ophthalmic surgeons to anticipate perioperative cardiac events, guide intraoperative management, and reduce postoperative morbidity. This introduction highlights the significance of systematic ECG assessment in patients undergoing cataract surgery, aiming to enhance patient safety through early detection and appropriate intervention.

Cataract surgery is one of the most common surgeries done in the elderly. Pre-operative assessment of general health apart from routine ocular investigations helps in anticipating intraoperative difficulties and effective management. Some health issues like silent Ischemia may be detected for the first time during preoperative assessment [1].

Even though majority of cataract surgeries are done in topical or local anaesthesia, some surgeries must be taken up under general anaesthesia. Patient’s apprehension and other co morbidities may warrant general anaesthesia. Safe anaesthesia requires some specific basic investigations like ECG [2], which is readily available in almost all health care facilities. Studies have shown that various cardiovascular diseases and cardiovascular risk factors have significantly higher odds ratio in patients undergoing cataract surgery [3].

Of all investigations, ECG is routinely ordered investigation for the elderly due to the prevalence of age-related cardiovascular changes [4]. ECG is a sophisticated galvanometer and sensitive electromagnet that can detect and record changes in electromagnetic potentials. The ECG (12-lead) is the primary clinical tool for non-invasive assessment of cardiac electrical function and is one of the most widely used, inexpensive, and convenient assessment modalities used to screen for cardiovascular disease [5, 6]. It is estimated that in 30% of preoperative ECG performed there is some abnormality, but that most of them are not significant to the point that change the plan of cataract surgery [7].

The present study aims to analyse and assess the electrocardiographic (ECG) patterns and their clinical implications in patients undergoing cataract surgery. Specifically, it seeks to identify the common ECG patterns observed in this patient population who are elderly with multiple co morbidities and undiagnosed illnesses and evaluate their implications and perioperative significance. At our hospital our policy is to evaluate all patients using standard 12-lead ECG. Majority of our patients are from the North Coastal Andhra Pradesh region.

Study Design: Hospital-based retrospective observational study.

Study Setting: Department of Ophthalmology, Government General Hospital, Vizianagaram, Andhra Pradesh.

Duration of the Study: 6 months

Sampling Method: Convenience sampling.

Sample Size:  152

Study Population: Patients aged between 45 years to 75 years attending OPD for cataract surgery in Ophthalmology department at GGH Vizianagaram, Andhra Pradesh.

Ethical Considerations: Prior permission was obtained from scientific committee (RC NO:SC:06/2025/002) and Institutional Ethics Committee (SERIAL NO:73/IEC GMC/ July 2025) Government Medical College, Vizianagaram.

Inclusion Criteria: All patients aged between 45yrs to 75 years attending OPD for cataract surgery after routine cataract investigations along with ECG in Ophthalmology department at the Government General Hospital, Vizianagaram.

Exclusion Criteria:  Patients with prior congenital cardiac disease, Patients above 75 years and children.

Study Parameter:

• Age (mean ± SD)
• Gender distribution
• Clinical Comorbidities:
• Hypertension
• Diabetes Mellitus
• History of Coronary Artery Disease (CAD)
• Smoking history
• Preoperative ECG Findings:
• Normal ECG
• Sinus Tachycardia
• Sinus Bradycardia
• Left Ventricular Hypertrophy (LVH)
• ST-T Segment Changes (Ischemic changes)

Statistical Analysis: -

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analysed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analysed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant

Table 1: Baseline Demographic and Clinical Characteristics

Table 2: Distribution of Preoperative ECG Findings

Table 3: Association of ECG Abnormalities with Comorbidities

Table 4: Need for Further Cardiology Evaluation or Delay

Figure 1: Distribution of Preoperative ECG Findings

Figure 2: Association of ECG Abnormalities with Comorbidities

In the present study population with a mean age of 66.4 ± 8.5 years, males comprised 53.9% and females 46.1% of the total, with no statistically significant gender difference (p = 0.16758). Among the comorbid conditions, hypertension was the most prevalent, observed in 48.7% of patients, followed by diabetes mellitus in 36.8%, both of which showed statistically significant associations (p = 0.021 and p = 0.045, respectively). A history of coronary artery disease (CAD) was noted in 18.4% of patients (p = 0.032), and smoking history was reported in 22.4%, also showing a significant association (p = 0.019).

In the present study, ECG findings revealed that 50% of patients had a normal ECG, with a significantly higher proportion among females (57.1%) compared to males (43.9%), showing statistical significance (p = 0.043). Sinus tachycardia was observed in 11.8% of patients, more common in males (14.6%) than females (8.6%), though the difference was not statistically significant (p = 0.172). Sinus bradycardia was seen in 9.2% of cases, with similar distribution between males (9.8%) and females (8.6%) (p = 0.805). Left ventricular hypertrophy (LVH) was noted in 14.5% of patients, again slightly more frequent in males (17.1%) than females (11.4%), without statistical significance (p = 0.324). Ischemic changes, particularly in ST-T segments, were also present in 14.5% of the population, with nearly equal prevalence among males (14.6%) and females (14.3%) (p = 0.966).

In this study, the presence of ECG abnormalities showed a significant association with several comorbid conditions. Hypertension was present in 63.2% of patients with abnormal ECGs compared to 34.2% with normal ECGs (p = 0.001), indicating a strong correlation. Similarly, diabetes mellitus was more frequent among those with ECG abnormalities (47.4%) than those with normal ECGs (26.3%), with statistical significance (p = 0.008). A striking difference was observed in the prevalence of coronary artery disease (CAD), which was present in 31.6% of patients with abnormal ECGs versus only 5.3% among those with normal findings (p < 0.001). Additionally, smoking history was more common in patients with ECG abnormalities (28.9%) compared to those with normal ECGs (15.8%), also showing a statistically significant association (p = 0.049).

In this study, abnormal ECG findings were significantly associated with increased need for further cardiology evaluation and surgical delays or cancellations. Among patients with abnormal ECGs, 36.8% required further cardiology referral compared to only 5.3% in the normal ECG group, while surgery was delayed or cancelled in 13.2% of the ECG abnormal group versus just 2.6% of those with normal ECGs. This association was statistically significant (p < 0.001).

In the present study involving patients undergoing preoperative evaluation, the mean age was 66.4 ± 8.5 years, with a nearly equal gender distribution, and no statistically significant sex-based difference. Notably, comorbid conditions such as hypertension (48.7%), diabetes mellitus (36.8%), history of coronary artery disease (18.4%), and smoking (22.4%) were significantly associated with the study population. ECG abnormalities were observed in 50% of patients, more frequently in males than females, and were strongly associated with the presence of comorbidities. Hypertension, diabetes mellitus, CAD, and smoking were significantly more common among those with abnormal ECG findings (p-values = 0.001, 0.008, <0.001, and 0.049 respectively). These findings are consistent with the observations made by Kumar et al., who reported that ECG abnormalities were significantly more prevalent in patients with cardiovascular risk factors, especially hypertension and diabetes mellitus [8].

The significant association of abnormal ECG with intraoperative events and delays in surgery was also highlighted in the work by Bhatia et al., who demonstrated that preoperative ECG abnormalities were predictive of intraoperative hemodynamic instability and were associated with the need for further cardiac assessment in 28% of cases [9]. Similarly, a study by Shabbir et al. emphasized the predictive value of ECG findings, especially ST-T changes, and LVH, in determining the likelihood of cardiac complications during surgery [10]. In our study, 36.8% of patients with abnormal ECGs required further cardiology referral, and 13.2% had surgery delayed or cancelled, significantly higher than the normal ECG group (5.3% and 2.6%, respectively; p < 0.001). This agrees with the findings of Bansal et al., who reported that abnormal ECG findings led to surgical postponement in 12% of patients [11].

Moreover, ischemic ECG changes, though equally distributed among genders in our study, have been identified as critical predictors of adverse outcomes in previous literature. For instance, Kapoor et al. found that ST-T abnormalities were strongly linked with underlying CAD and often necessitated preoperative optimization [12]. Comparable findings were reported by Singh et al., who observed that even minor ECG changes often unmasked subclinical cardiac disease, especially in diabetic and hypertensive patients [13]. The current study reinforces this notion, as the highest prevalence of ECG abnormalities was among those with CAD (31.6%).

While sinus tachycardia and bradycardia did not significantly differ between genders in our study, these findings align with the work of Patel et al., who reported that minor conduction disturbances on ECG may not correlate with gender but should still prompt closer cardiac evaluation in patients with risk factors [14]. Left ventricular hypertrophy (LVH), observed in 14.5% of our patients, has been reported by Sharma et al. as a marker of chronic hypertension and a predictor of perioperative arrhythmias and myocardial stress [15].

Furthermore, the integration of ECG findings in the preoperative workup is supported by international guidelines, such as those summarized by the American College of Cardiology and American Heart Association (ACC/AHA), which advocate ECG screening in patients over 65 years or those with cardiovascular risk factors [16]. The value of such screening has been further validated in studies like that by Das et al., who found ECG to be a cost-effective and accessible tool for risk stratification in surgical patients, particularly in resource-limited settings [17].

Taken together, our findings support the routine use of preoperative ECG, especially in older adults and those with comorbidities. Abnormal ECG findings not only reflect a higher burden of cardiovascular disease but also predict intraoperative and perioperative complications, influence surgical planning, and may necessitate further cardiologic evaluation.

The findings of this study underscore the critical role of preoperative ECG screening in identifying patients with cardiac abnormalities who were admitted for cataract surgery. A significant proportion of the study population exhibited ECG abnormalities, which were strongly associated with underlying comorbid conditions such as hypertension, diabetes mellitus, coronary artery disease, and smoking. Furthermore, the presence of ECG abnormalities significantly increased the likelihood of requiring further cardiologic evaluation and led to delays or cancellations of planned surgical procedures. These outcomes highlight the value of routine ECG assessment as a simple, non-invasive, and cost-effective tool in preoperative risk stratification, particularly in older adults and those with established cardiovascular risk factors. Early identification and appropriate management of such patients can contribute to improved perioperative safety, better resource planning, and optimized surgical outcomes.

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