ObjectiveTo assess the effectiveness of routine intensive care unit surveillance compared with frequent 12-lead electrocardiogram monitoring for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia in vascular surgery patients.DesignProspective cohort trial.SettingIntensive care unit.ParticipantsWe studied 149 patients undergoing elective infrainguinal or aortic vascular surgery who were admitted to the intensive care unit postoperatively.InterventionsPatients were simultaneously monitored with a 10-electrode/12-lead electrocardiogram obtained every 2 mins (criterion standard) and routine intensive care unit surveillance that included standard monitoring (five-electrode/two-lead electrocardiogram with ST segment trends and routine 12-lead electrocardiogram) and clinical assessment for detecting myocardial ischemia. The results of the criterion standard were not available to the caregivers.Measurements and Main ResultsWe measured the ability of routine intensive care unit surveillance to detect the first 20 mins of electrocardiogram evidence suggestive of myocardial ischemia, defined as ST segment depression or elevation of ≥1 mm in two consecutive leads, during the first postoperative day. Seventeen patients (11%) had electrocardiogram evidence suggestive of prolonged myocardial ischemia, the majority of which occurred in leads V2–V4. The sensitivity of routine intensive care unit surveillance for detecting the first episode of electrocardiogram evidence suggestive of prolonged myocardial ischemia in a patient was 12% (95% confidence interval, 7–17%), and the specificity was 98% (95% confidence interval, 95–100%) with a positive predictive value of 40% (95% confidence interval, 32–48%), a negative predictive value of 90% (95% confidence interval, 85–94%), a positive likelihood ratio of 6, and a negative likelihood ratio of 1. The sensitivity of routine intensive care unit surveillance for detecting all episodes was 3% (95% confidence interval, 2–3%) and the specificity 99% (95% confidence interval, 99–100%) per 20-min monitoring interval, with a positive predictive value of 17% (95% confidence interval, 16–18%), negative predictive value of 95% (95% confidence interval, 95–96%), positive likelihood ratio of 3, and negative likelihood ratio of 1.ConclusionsRoutine intensive care unit surveillance has low sensitivity for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia compared with frequent 12-lead electrocardiograms. Because detecting electrocardiogram evidence suggestive of prolonged postoperative myocardial ischemia is important, physicians should consider alternative strategies to detect myocardial ischemia.