Roger Chou, MD; for the High Value Care Task Force of the American College of Physicians *
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Disclosures: Dr. Chou reports grants from the American College of Physicians during the conduct of the study and grants from the Agency for Healthcare Research and Quality outside the submitted work. Dr. Moyer reports that she is Chair of the American College of Physicians Board of Governors for 2014–2015. Dr. Skeff reports a consultancy for Wolters Kluwer Health outside the submitted work. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterest Forms.do?msNum=M14-1225. A record of conflicts of interest is kept for each High Value Care Task Force meeting and conference call and can be viewed at http://hvc.acponline.org/clinrec.html.
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Author Contributions: Conception and design: R. Chou.
Analysis and interpretation of the data: R. Chou.
Drafting of the article: R. Chou.
Critical revision of the article for important intellectual content: R. Chou.
Final approval of the article: R. Chou.
Collection and assembly of data: R. Chou.
Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies.
Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults.
Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.
Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.
Table 1. Estimated Costs of Cardiac Screening Tests
Table 2. Estimated 10-y Probability of Coronary Heart Disease Based on Traditional Risk Factors
Table 3. Cardiovascular Risk Calculators
Summary of the American College of Physicians advice for high-value care on cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging.
Paul Zimmermann, M.D.
South Carolina Health
March 25, 2015
Cardiac Screening: Advice for High Vale Care
The Chou article(1) on cardiac screening recommends that resting ECGs should not be performed in asymptomatic adults. I find this recommendation, in many instances, going against the standard of care. It is standard to get ECGs on athletes for screenings, who, by definition, are asymptomatic. The European community(2) continues to find this intervention cost effective. In finding against screening ECGs, Chou et.al. cite two articles showing limited utility of ECGs. One by Rubenstein and Greenfield JAMA 1980 (3) found ‘the routine ECG has little value as a baseline’. But in their article, they referenced 5% of patients were grouped into a class that ECGs could be useful. 5% of patients seems pretty important to me. The other report by Hoffman and Igarashi(4) recommend against routine ordering ECGs in patients with chest pain. This conclusion today is consistent with medical malpractice. I am in agreement with the finding that stress testing is overutilized. I find that extending the argument to resting ECGs to be an unwanted stretch.References1.Chou R, High Value Task Force ACP. Cardiac screening with, stress echocardiography, or myocardial perfusion: Advice for High Value care from the ACP. Ann Int Med. 2015; 162:438-447.2.Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007; 116:2616-226.3.Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac symptoms. JAMA 1980; 244:2536-2539.4.Hoffman JR, Igarashi E. Influence of electrocardiographic findings in admission decisions in patients with acute chest pain. Am J Med 1985; 79:699-707.
Roger Chou, MD
Oregon Health & Science University
May 4, 2015
As described in the methods, our article on cardiac screening explicitly excluded preparticipation evaluation of athletes (1) thus the cited articles on screening of athletes are not relevant to it. To clarify the findings of the Rubenstein study, it found that in chest pain patients presenting to the emergency room, 5% (11/236) might have had an admission avoided if a baseline ECG had been available (2). However, this is a maximal estimate, as 9 of the 11 patients did not have a baseline ECG, and how many admissions would have actually been avoided is unknown. Further, the authors found no cases in which an inappropriate discharge was avoided because a baseline ECG was available. The Hoffman study found that baseline ECG’s were not helpful in admission decisions in any of 84 patients presenting to the ER with acute chest pain (3). Its findings regarding the utility of ECG’s for evaluation of acute chest pain are not relevant to our article, which only address screening of asymptomatic persons. Nonetheless, it is misleading to suggest that the Hoffman study recommends against appropriate use of ECG’s in this setting. Rather, it states that ECG’s may not be necessary in patients with chest pain that is unlikely to be due to cardiac ischemia based on history and examination (e.g., chest pain that is obviously musculoskeletal or due to esophageal reflux disease, or chest pain with very atypical features in a young adult).
1. Chou R. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med 2015;162:43-47.
2. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA 1980;244:2536-9.
3. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med 1985;79:699-707.
Chou R, for the High Value Care Task Force of the American College of Physicians. Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2015;162:438–447. doi: https://doi.org/10.7326/M14-1225
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Published: Ann Intern Med. 2015;162(6):438-447.
Cardiac Diagnosis and Imaging, Cardiology, Guidelines, High Value Care, Prevention/Screening.
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