Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians

Roger Chou

doi:10.7326/M14-1225

Clinical Guidelines |17 March 2015

Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians Free

Roger Chou, MD; for the High Value Care Task Force of the American College of Physicians *

Article, Author, and Disclosure Information

Abstract

Background:

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.

Methods:

Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults.

Results:

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.

High-Value Care Advice:

Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

Cardiovascular disease results in 1 of every 3 deaths in the United States, or approximately 800 000 per year (1). Coronary heart disease (CHD) accounts for more than half of all cardiovascular events in adults younger than 75 years and is the leading cause of death (2). Direct and indirect costs of CHD in 2009 were estimated at $195 billion (2).

An important challenge in preventing the negative consequences of CHD is that its first clinical manifestation can be catastrophic, including sudden cardiac death or acute myocardial infarction (3). Among those who die suddenly of CHD, more than half have no antecedent symptoms (2). In addition, myocardial infarction is frequently silent (4, 5), causing no recognized symptoms but negatively affecting prognosis (4, 5).

“Screening” refers to testing for a disease or condition in asymptomatic persons to identify the condition before it manifests clinically. Several tests are available to screen for CHD, including resting or stress electrocardiography (ECG) and stress testing in conjunction with cardiac imaging with echocardiography or myocardial perfusion imaging (MPI) (Table 1) (6–10). Electrocardiography is among the most commonly performed diagnostic tests in the United States, and the use of cardiac imaging studies is increasing (11–13), although reliable data are not available on the number of screening studies performed.

Table 1. Estimated Costs of Cardiac Screening Tests

Despite its intuitive appeal, the benefit of cardiac screening in low-risk adults has long been questioned (14, 15). For screening to be warranted, showing that tests can accurately identify unrecognized CHD or determine the level of risk is insufficient. The findings must also lead to actions resulting in improvements in clinical outcomes that are superior to those resulting from delaying treatment until symptoms appear (16, 17). Most important, the benefits should be greater than what is observed on the basis of risk assessment without such testing (for example, assessment of traditional cardiovascular risk factors, such as age, sex, lipid levels, blood pressure, smoking status, and presence of diabetes) and must outweigh any harms, all at an acceptable cost relative to the benefits (18). Costs of testing include both the direct costs of the procedure itself (Table 1) and downstream costs from additional tests, follow-up, and referrals. In some cases, screening can lead to invasive follow-up tests, such as angiography, and procedures, such as percutaneous revascularization, with their attendant costs and harms. It is therefore important to critically examine practices around cardiac testing. Inappropriate cardiac testing in low-risk adults has been identified by several professional organizations, including the American College of Physicians (ACP), as one of the most overused clinical practices (19). The purpose of this article is to provide practical advice on cardiac screening with ECG, stress echocardiography, or MPI. It does not address the use of coronary computed tomography or nontraditional risk factors, such as C-reactive protein levels or carotid intima–media thickness (20).

Methods

The evidence in this article came from a systematic review (21) and recommendations from the U.S. Preventive Services Task Force (USPSTF) on screening with ECG (22); guidelines and standards developed by the American College of Cardiology in conjunction with other professional societies (7, 23, 24); and articles on the yield, benefits, and harms of cardiac screening. This article is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence. The target audience is all clinicians, and the target patient population is asymptomatic, low-risk adults (defined as those with an estimated 10-year risk for CHD events of <10% [25] unless otherwise noted). This article does not address screening of children or adolescents, preparticipation screening of athletes, preoperative evaluation, ECG screening for purposes of drug monitoring, or evaluation of symptoms suggestive of cardiac disease (20, 26). The article was reviewed and approved by the ACP's High Value Care Task Force, whose members are physicians trained in internal medicine and its subspecialties and experts in evidence synthesis. At each meeting, all members of the task force declared any potentially relevant financial and nonfinancial conflicts of interest.

What Are the Evidence-Based Recommendations for the Use of Cardiac Testing in Asymptomatic Adults?

The USPSTF recommends against screening low-risk adults with rest or exercise ECG (22). Other groups also do not recommend ECG screening in this population (7, 27–29). A search for primary care, cardiology, or radiology guidelines that recommend cardiac screening in low-risk adults found none.

A systematic review commissioned by the USPSTF found that many abnormalities on screening rest or exercise ECG are associated with an increased risk for subsequent cardiovascular events after adjustment for traditional risk factors (21). However, it found no study on effects of screening on clinical outcomes or on the use of risk-reducing therapies, such as statins or aspirin. In addition, the predictive utility of abnormal findings was relatively weak (pooled adjusted hazard ratios ranged from 1.4 to 2.1), and no study evaluated how accurately resting or exercise ECG reclassified participants into different risk categories compared with traditional risk factor assessment alone (30–33). Although 1 study published after the USPSTF review reported reclassification rates after resting ECG in a population of older adults with a high prevalence of baseline ECG abnormalities, effects were most pronounced in intermediate-risk patients and the reclassification rate in low-risk patients was not reported (34). This is a critical research gap given that treatment decisions about cardiovascular risk–reducing therapies are often based on the 10-year risk classification level (25, 35), although the thresholds used to categorize risk vary (for example, <10% [25] vs. <7.5% [36] for low risk). Regardless of the threshold used (37), in populations at very low risk (≤5%) for CHD events, the presence of a screening ECG abnormality will generally not move a patient from a lower-risk to a higher-risk category, resulting in little effect on clinical treatment decisions. Based on the Framingham Risk Score, this includes almost all nondiabetic women of any age without cardiovascular risk factors (total cholesterol level >5.2 mmol/L [>200 mg/dL], high-density lipoprotein cholesterol level <1.3 mmol/L [<50 mg/dL], smoker, and hypertensive or normotensive while receiving treatment), women younger than 60 years with 1 or 2 risk factors, and men younger than 55 years with no risk factors (Table 2). For example, a 60-year-old woman with average lipid levels (total cholesterol level of 5.5 mmol/L [211 mg/dL] and high-density lipoprotein cholesterol level of 1.5 mmol/L [59 mg/dL]) (38) and no other risk factors would have a 10-year estimated risk for CHD of 2%. Based on an adjusted hazard ratio of 1.5, the presence of left bundle branch block on ECG would increase this patient's risk to about 3%—still well within the low-risk category.

Table 2. Estimated 10-y Probability of Coronary Heart Disease Based on Traditional Risk Factors

Similarly, the American College of Cardiology Foundation and the American Heart Association recommend against stress echocardiography or MPI for cardiovascular risk assessment in low-risk, asymptomatic adults (23). These recommendations are based on the lack of evidence showing that screening improves clinical outcomes, unclear effects on risk reclassification and the use of risk-reducing therapies, and the relatively low prevalence of disease. Appropriate use criteria have also been developed to help evaluate imaging use patterns and identify areas of overuse and underuse (39, 40). Consistent with clinical practice guidelines, appropriate use criteria jointly developed by several professional societies classify screening of low-risk adults as generally not appropriate (24, 41).

One reason that cardiac screening in low-risk patients might be ineffective is that for many of the abnormalities found, there is no proven, effective treatment. For example, treatments for left ventricular hypertrophy that improve clinical outcomes (other than blood pressure management) are lacking (42). Similarly, there are no clear treatments for asymptomatic bundle branch block or nonspecific repolarization abnormalities on ECG. Although exercise training can alleviate chronotropic incompetence and impaired exercise tolerance or functional capacity, such interventions have not been shown to reduce CHD events (43). Conversely, interventions for modifiable CHD risk factors, such as smoking, hypertension, diabetes, and overweight, are generally indicated regardless of cardiac screening test findings.

For silent ischemia, evidence is also insufficient to determine whether treatment prolongs life. Although older randomized trials found evidence of beneficial effects of treatment with atenolol or coronary revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery) for silent ischemia, the differences were not statistically significant for atenolol (relative risk, 0.55 [95% CI, 0.22 to 1.33]). In addition, drug therapies were not optimized and do not reflect current practice, and 25% to 30% of patients previously had revascularization, which limits generalizability to screening (44, 45).

Another potential use of screening ECG is as a baseline study for future comparison when symptoms develop. However, limited evidence suggests that having ECG at baseline rarely affects clinical decisions (46, 47).

The effectiveness of cardiac screening in low-risk adults is also limited by the small number of patients who might benefit from revascularization. In addition to the low overall CHD prevalence, only a small subset of patients will have the type of CHD in which revascularization is associated with survival benefit (left main disease or ≥70% stenosis in ≥2 major coronary arteries, particularly with left anterior descending artery involvement) (48, 49). In the well-conducted Coronary Artery Surgery Study, among patients having coronary angiography for evaluation of nonspecific chest pain, 40% of men and 24% of women had coronary atherosclerosis, but only 3% and 0.6%, respectively, had at least 50% left main stenosis or at least 70% 3-vessel stenosis (50). Although revascularization can be appropriate for symptom relief in patients with lesser degrees of CHD, such benefits obviously cannot be experienced by asymptomatic patients. In addition, most trials showing benefits of revascularization were conducted before the routine use of aspirin, β-blockers, and statins. More recent high-quality evidence suggests that outcomes of revascularization may be similar to those of current optimal medical therapy in symptomatic patients, including those with multivessel disease (51). No trial compared outcomes of revascularization versus medical therapy in asymptomatic patients, but benefits are unlikely given the lower incidence of cardiovascular events.

What Are the Potential Harms of Screening?

Potential harms are a particularly important consideration for screening because patients are asymptomatic and any harms are iatrogenic. More than 90% of low-risk adults will not have a cardiac event in the next 10 years and cannot benefit from additional cardiac screening over that period.

Direct harms seem to be trivial for resting ECG and minimal for exercise ECG (52, 53). For the latter, the overall estimated risk for sudden death or an event requiring hospitalization is about 1 per 10 000 tests (53). Pharmacologic agents to induce stress can cause myocardial ischemia, arrhythmia, hypotension, bronchospasm, and other symptoms, although rates of serious adverse events seem to be low (54, 55).

Myocardial perfusion imaging results in radiation exposure from the use of radionuclide tracers. Medical imaging procedures are the primary source of radiation exposure, with higher cumulative exposure associated with increased risk for subsequent cancer (56). Myocardial perfusion imaging is associated with an average effective radiation dose of 15.6 mSv compared with 0.02 mSv for posteroanterior chest radiography and 8 mSv for abdominal computed tomography (56, 57). One study of persons aged 50 years estimated a risk of 2 to 25 additional cancer cases per 10 000 MPI scans (58), depending on the imaging technique and tracers used.

Harms may also occur due to false-positive results. In low-prevalence populations, even screening tests with high sensitivity and specificity are associated with a low positive predictive value (high rate of false-positive results) (59). Up to three quarters of asymptomatic men with exercise-induced ST-segment depression on ECG have no significant angiographic coronary artery disease (21, 60). Because resting ECG is less accurate, the positive predictive value is even lower. Although the accuracy of stress imaging is higher than that of stress ECG, the positive predictive value is still relatively low (61, 62). Based on a positive likelihood ratio of 8.6 (CI, 5.9 to 12) for stress echocardiography (59), in a population with a pretest probability of CHD of 5%, the estimated posttest probability after a positive test result would be only 31% (61).

Harmful effects may also occur in patients with true-positive screening results because of labeling, health insurance denials, or increased insurance premiums. However, evidence on effects of such harms as a result of cardiac screening is not available.

Harms may also result from follow-up testing and interventions. In studies of asymptomatic or primarily asymptomatic patients, rates of subsequent angiography after an abnormal exercise ECG result ranged from 0.6% to 2.9% (21, 63, 64). In 2 studies, 0.1% and 0.5% of patients who had screening exercise ECG had a revascularization procedure that may have been unnecessary (63, 64). A significant proportion of inappropriate percutaneous coronary interventions are related to treatment of asymptomatic patients. One study of national registry data classified 11.6% of procedures as inappropriate, with more than half of these performed in persons without angina (65).

Downstream harms can occur as a result of these follow-up tests and interventions. Angiography is associated with a risk of about 1.7% for serious adverse events, including death (0.1%), myocardial infarction (0.05%), stroke (0.07%), and arrhythmia (0.4%) (66). Coronary angiography is associated with an average effective radiation dose of 7 mSv (56), and follow-up tests after cardiac screening, such as computed tomography, coronary angiography, and MPI, are also associated with radiation exposure.

Does Practice Follow the Evidence?

Despite widespread concordance among clinical practice guidelines, cardiac screening tests are still frequently done in clinical practice, and their use may be increasing. One study of national survey data found that screening ECG use at general medical examination visits increased from 6.1% to 11.3% from 1999 to 2009 (67). A systematic review found overuse rates of 9.2% for ECG and 3.0% to 52% for cardiac stress tests (68). In a Consumer Reports survey, 39% of asymptomatic adults without high blood pressure or a high cholesterol level reported having ECG within the past 5 years, and 12% reported undergoing exercise ECG (69). More than half reported that their physician recommended it as part of their routine health care.

For cardiac stress imaging, 3 studies found that about 15% of stress MPI and echocardiography examinations did not meet appropriateness criteria, with evaluation of low-risk, asymptomatic patients accounting for about half of the cases in 2 studies and 25% in the other (70–72).

What Forces Promote the Overuse of Cardiac Testing in Asymptomatic Adults?

Several factors may promote overuse of cardiac testing in asymptomatic adults. Clinicians may overestimate the benefits of revascularization on the basis of trials of symptomatic patients that used outdated medical treatment regimens (55, 73). In addition, harms may be underestimated. False-positive results are often overlooked as harms, even though they may result in unnecessary tests and treatment. Harms related to downstream tests and interventions may be unrecognized, and effects of radiation exposure may not manifest for years.

Clinicians may also assume that negative cardiac screening test results provide some benefit by reassuring patients. However, a search identified no studies to support this assumption.

Financial incentives may also promote unnecessary testing. One study based on Medicare data found greater relative increases in payments for MPIs (a relatively highly reimbursed procedure) to cardiologists than radiologists, suggesting a potential increase in inappropriate self-referrals by cardiologists (74). Another study found that follow-up stress MPI and echocardiography after revascularization procedures were more frequent among patients treated by physicians who billed for technical or professional fees than those who did not bill for those services (75).

Patients often overestimate the effectiveness of early detection and preventive interventions (73, 76), potentially leading to overenthusiasm for screening tests in general (77). One study of cancer screening found that nearly three quarters of respondents preferred a total-body computed tomographic scan over $1000 in cash (78). Such expectations are often communicated to physicians and affect clinical decisions, and they may be particularly influential when patient satisfaction is linked to financial incentives (79). Past experiences in receiving cardiac screening tests may also condition patient expectations around future screening. In some cases, cardiac screening is offered as part of a routine physical examination “package.”

Direct-to-consumer cardiac screening, which often includes ECG and other cardiac testing, can bypass clinicians seeking to serve as conscientious gatekeepers. Such screening often takes advantage of consumer concerns about cardiac disease and promotes messages of patient empowerment but provides little in the way of informed decision making, clinical oversight, or follow-up (80).

Overuse of cardiac testing could also be related to the perceived risk for missing a serious diagnosis (81). Cardiac testing may be viewed as a way to protect against lawsuits related to such cases. “Defensive medicine” is the alteration of clinical behavior due to concerns over malpractice liability, with unnecessary diagnostic testing the most frequently reported defensive act (82).

How Can Physicians Reduce Overuse of Cardiac Testing?

Adhering to recommendations to not perform cardiac screening with ECG, MPI, or echocardiography in low-risk patients would help reduce overuse. Cardiovascular risk assessment should start with a global risk score that combines individual risk factor measurements into a single quantitative estimate of risk (81). Many global risk calculators are available, although the risk factors and populations addressed vary (Table 3). For example, the Framingham Risk Score, which was developed and validated in U.S. populations, excludes patients with diabetes and does not incorporate family history of early CHD. Although some tools include these risk factors, they have not been as extensively validated as the Framingham Risk Score in U.S. cohorts (83). Early CHD (typically defined as occurring in a first-degree male relative aged <55 years or a first-degree female relative aged <65 years) is a relatively modest predictor of CHD, with a relative risk of 1.5 to 2.0 after adjustment for other factors (23). Some guidelines consider diabetes a “CHD equivalent” for the purposes of risk categorization (25). Regardless of the risk calculator used, patients can be classified as low-risk according to specified thresholds (for example, 10-year risk for a CHD event of <7.5% or <10%). In patients in the low-risk category, cardiac screening is not indicated. Rather, strategies should focus on treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.

Table 3. Cardiovascular Risk Calculators

Recommendations for cardiac screening in higher-risk patients are less clear-cut (84). The USPSTF found insufficient evidence to determine whether benefits of screening ECG outweigh harms (22), and the American College of Cardiology Foundation and American Heart Association recommend MPI as a potential option for cardiovascular risk assessment in high-risk patients (23). These recommendations are based on the higher prevalence of disease as well as the greater likelihood that findings could affect treatment decisions. Indeed, the greatest potential benefits of screening may be in patients with assessed risk close to the threshold for interventions. One study of adults aged 70 to 79 years that was published after the USPSTF review found that resting ECG correctly reclassified 14% of intermediate-risk adults (34). However, evidence on effects of cardiac screening on clinical outcomes in higher-risk patients is sparse and does not clearly show clinical benefits (85), and cost-effectiveness is uncertain (86). If screening is considered in patients with assessed risk close to treatment thresholds, it is important that they be informed of the important evidence gaps and potential harms before being screened. In patients who meet criteria for treatment on the basis of traditional risk factor assessment, further cardiac screening may be of limited value. Because of the lack of demonstrated benefits, high costs, and potential harms, coronary angiography and revascularization procedures are generally not indicated after cardiac screening, even in high-risk, asymptomatic patients (87).

Efforts to decrease overuse of cardiac screening in low-risk adults should address factors contributing to overuse. Clinician incentives should be based on delivery of appropriate care and not primarily on patient satisfaction, which could reward unnecessary testing. Efforts to reduce overuse related to physician self-referral are also important (88, 89). Enhanced oversight of direct-to-consumer cardiovascular screening is needed, including requirements for informed consent, counseling, and access to follow-up care (90).

Reducing inappropriate cardiac testing practices in clinical practice can be a challenge (91, 92). Efforts are likely to be more effective when they are more active and include individualized feedback (13). The use of health information technology, such as computer-based reminders about appropriate indications for testing at the time the order is placed, is another promising strategy (93).

Conclusion

Health care practices associated with high costs and limited or no benefits provide little value. There is no evidence that cardiac screening of low-risk adults with resting or stress ECG, stress echocardiography, or stress MPI improves patient outcomes, but it is associated with increased costs and potential harms. Implementing recommendations that focus on initial cardiovascular risk assessment based on traditional cardiovascular risk factors and using a global risk score, addressing modifiable risk factors, and not performing additional cardiac screening in low-risk patients would improve patient care while avoiding unnecessary harms and costs. To be most effective, efforts to reduce the use of imaging should be multifocal and should address clinician behaviors, patient expectations, direct-to-consumer screening programs, and financial incentives.

ACP High-Value Care Advice

High-Value Care Advice: Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

Screening with rest or stress ECG or stress cardiac imaging is not indicated in asymptomatic, low-risk patients. In this 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.

The Figure summarizes the recommendation and clinical considerations.

Figure.

Summary of the American College of Physicians advice for high-value care on cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging.

References

Mensah
GA
,
Brown
DW
.
An overview of cardiovascular disease burden in the United States.
Health Aff (Millwood)
2007
26
38
48
PubMed
CrossRef

PubMed
Go
AS
,
Mozaffarian
D
,
Roger
VL
,
Benjamin
EJ
,
Berry
JD
,
Borden
WB
.
et al
American Heart Association Statistics Committee and Stroke Statistics Subcommittee
Heart disease and stroke statistics—2013 update: a report from the American Heart Association.
Circulation
2013
127
e6
e245
PubMed
CrossRef

PubMed
Lerner
DJ
,
Kannel
WB
.
Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population.
Am Heart J
1986
111
383
90
PubMed
CrossRef

PubMed
Sheifer
SE
,
Gersh
BJ
,
Yanez
ND
3rd
,
Ades
PA
,
Burke
GL
,
Manolio
TA
.
Prevalence, predisposing factors, and prognosis of clinically unrecognized myocardial infarction in the elderly.
J Am Coll Cardiol
2000
35
119
26
PubMed
CrossRef

PubMed
Sigurdsson
E
,
Thorgeirsson
G
,
Sigvaldason
H
,
Sigfusson
N
.
Unrecognized myocardial infarction: epidemiology, clinical characteristics, and the prognostic role of angina pectoris. The Reykjavik Study.
Ann Intern Med
1995
122
96
102
CrossRef

PubMed
Hendel
RC
,
Abbott
BG
,
Bateman
TM
,
Blankstein
R
,
Calnon
DA
,
Leppo
JA
.
et al
American Society of Nuclear Cardiology
The role of radionuclide myocardial perfusion imaging for asymptomatic individuals.
J Nucl Cardiol
2011
18
3
15
PubMed
CrossRef

PubMed
Lauer
M
,
Froelicher
ES
,
Williams
M
,
Kligfield
P
.
American Heart Association Council on Clinical Cardiology
Subcommitteeon Exercise, Cardiac Rehabilitation, and Prevention
Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention.
Circulation
2005
112
771
6
PubMed
CrossRef

PubMed
Marwick
TH
.
Stress echocardiography.
Heart
2003
89
113
8
PubMed
CrossRef

PubMed
Picano
E
.
Stress echocardiography: a historical perspective.
Am J Med
2003
114
126
30
PubMed
CrossRef

PubMed
von Elm
E
,
Altman
DG
,
Egger
M
,
Pocock
SJ
,
Gøtzsche
PC
,
Vandenbroucke
JP
.
STROBE Initiative
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
Ann Intern Med
2007
147
573
7
CrossRef

PubMed
Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2010 Summary Tables. Atlanta, GA: Centers for Disease Control and Prevention; 2010. Accessed at www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf on 6 June 2014.
Levin
DC
,
Rao
VM
,
Parker
L
,
Frangos
AJ
,
Sunshine
JH
.
Recent trends in utilization of cardiovascular imaging: how important are they for radiology?
J Am Coll Radiol
2005
2
736
9
PubMed
CrossRef

PubMed
Stafford
RS
.
Feedback intervention to reduce routine electrocardiogram use in primary care.
Am Heart J
2003
145
979
85
PubMed
CrossRef

PubMed
Sox
HC
Jr
,
Garber
AM
,
Littenberg
B
.
The resting electrocardiogram as a screening test. A clinical analysis.
Ann Intern Med
1989
111
489
502
CrossRef

PubMed
Sox
HC
Jr
,
Littenberg
B
,
Garber
AM
.
The role of exercise testing in screening for coronary artery disease.
Ann Intern Med
1989
110
456
69
CrossRef

PubMed
Frame
PS
,
Carlson
SJ
.
A critical review of periodic health screening using specific screening criteria. Part 1: selected diseases of respiratory, cardiovascular, and central nervous systems.
J Fam Pract
1975
2
29
36
PubMed
PubMed
Woolf
SH
,
Battista
RN
,
Anderson
GM
,
Logan
AG
,
Wang
E
.
Assessing the clinical effectiveness of preventive maneuvers: analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations. A report by the Canadian Task Force on the Periodic Health Examination.
J Clin Epidemiol
1990
43
891
905
PubMed
CrossRef

PubMed
Owens
DK
,
Qaseem
A
,
Chou
R
,
Shekelle
P
.
Clinical Guidelines Committee of the American College of Physicians
High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.
Ann Intern Med
2011
154
174
80
CrossRef

PubMed
ABIM Foundation. Choosing Wisely: Five Things Physicians and Patients Should Question. Philadelphia: ABIM Foundation; 2014. Accessed at www.choosingwisely.org/doctor-patient-lists/american-college-of-physicians on 6 June 2014.
Helfand
M
,
Buckley
DI
,
Freeman
M
,
Fu
R
,
Rogers
K
,
Fleming
C
.
et al
Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the U.S. Preventive Services Task Force.
Ann Intern Med
2009
151
496
507
CrossRef

PubMed
Chou
R
,
Arora
B
,
Dana
T
,
Fu
R
,
Walker
M
,
Humphrey
L
.
Screening asymptomatic adults with resting or exercise electrocardiography: a review of the evidence for the U.S. Preventive Services Task Force.
Ann Intern Med
2011
155
375
85
CrossRef

PubMed
Moyer
VA
.
U.S. Preventive Services Task Force
Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med
2012
157
512
8
PubMed
Greenland
P
,
Alpert
JS
,
Beller
GA
,
Benjamin
EJ
,
Budoff
MJ
,
Fayad
ZA
.
et al
American College of Cardiology Foundation
2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol
2010
56
e50
103
PubMed
CrossRef

PubMed
Douglas
PS
,
Khandheria
B
,
Stainback
RF
,
Weissman
NJ
,
Peterson
ED
,
Hendel
RC
.
et al
American College of Cardiology Foundation
ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.
J Am Coll Cardiol
2008
51
1127
47
PubMed
CrossRef

PubMed
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report.
Circulation
2002
106
3143
421
PubMed
PubMed
Buckley
DI
,
Fu
R
,
Freeman
M
,
Rogers
K
,
Helfand
M
.
C-reactive protein as a risk factor for coronary heart disease: a systematic review and meta-analyses for the U.S. Preventive Services Task Force.
Ann Intern Med
2009
151
483
95
CrossRef

PubMed
American Academy of Family Physicians
Recommendations for clinical preventive services.
Leawood, KS
American Academy of Family Physicians
2010
Balady
GJ
,
Franklin
BA
,
Whaley
MH
,
Howley
ET
.
ACSM's Guidelines for Exercise Testing and Prescription. 6th ed.
Philadelphia
Lippincott Williams & Wilkins
2000
Lim
LS
,
Haq
N
,
Mahmood
S
,
Hoeksema
L
.
ACPM Prevention Practice Committee
Atherosclerotic cardiovascular disease screening in adults: American College of Preventive Medicine position statement on preventive practice.
Am J Prev Med
2011
40
381
PubMed
PubMed
Janes
H
,
Pepe
MS
,
Gu
W
.
Assessing the value of risk predictions by using risk stratification tables.
Ann Intern Med
2008
149
751
60
CrossRef

PubMed
Cook
NR
,
Buring
JE
,
Ridker
PM
.
The effect of including C-reactive protein in cardiovascular risk prediction models for women.
Ann Intern Med
2006
145
21
9
CrossRef

PubMed
Pencina
MJ
,
D'Agostino
RB
Sr
,
D'Agostino
RB
Jr
,
Vasan
RS
.
Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
Stat Med
2008
27
157
72
PubMed
CrossRef

PubMed
Cook
NR
.
Statistical evaluation of prognostic versus diagnostic models: beyond the ROC curve.
Clin Chem
2008
54
17
23
PubMed
CrossRef

PubMed
Auer
R
,
Bauer
DC
,
Marques-Vidal
P
,
Butler
J
,
Min
LJ
,
Cornuz
J
.
et al
Health ABC Study
Association of major and minor ECG abnormalities with coronary heart disease events.
JAMA
2012
307
1497
505
PubMed
CrossRef

PubMed
U.S. Preventive Services Task Force
Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med
2009
150
396
404
CrossRef

PubMed
Stone
NJ
,
Robinson
JG
,
Lichtenstein
AH
,
BaireyMerz
CN
,
Blum
CB
,
Eckel
RH
.
et al
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation
2014
129
S1
45
PubMed
CrossRef

PubMed
Abramson
JD
,
Rosenberg
HG
,
Jewell
N
,
Wright
JM
.
Should people at low risk of cardiovascular disease take a statin?
BMJ
2013
347
f6123
PubMed
CrossRef

PubMed
Carroll
MD
,
Kit
BK
,
Lacher
DA
.
Total and high-density lipoprotein cholesterol in adults: National Health and Nutrition Examination Survey, 2009–2010.
NCHS Data Brief
2012
1
8
Fitch
K
,
Bernstein
SJ
,
Aguilar
MS
,
Burnand
B
,
LaCalle
JR
,
Lazaro
P
.
et al
The RAND/UCLA Appropriateness Method User's Manual.
Santa Monica, CA
RAND Corporation
2001
Patel
MR
,
Spertus
JA
,
Brindis
RG
,
Hendel
RC
,
Douglas
PS
,
Peterson
ED
.
et al
American College of Cardiology Foundation
ACCF proposed method for evaluating the appropriateness of cardiovascular imaging.
J Am Coll Cardiol
2005
46
1606
13
PubMed
CrossRef

PubMed
Hendel
RC
,
Berman
DS
,
DiCarli
MF
,
Heidenreich
PA
,
Henkin
RE
,
Pellikka
PA
.
et al
American College of Cardiology Foundation Appropriate Use Criteria Task Force
ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine.
J Am Coll Cardiol
2009
53
2201
29
PubMed
CrossRef

PubMed
Lauer
MS
.
What now with screening electrocardiography? [Editorial].
Ann Intern Med
2011
155
395
7
CrossRef

PubMed
Brubaker
PH
,
Kitzman
DW
.
Chronotropic incompetence: causes, consequences, and management.
Circulation
2011
123
1010
20
PubMed
CrossRef

PubMed
Pepine
CJ
,
Cohn
PF
,
Deedwania
PC
,
Gibson
RS
,
Handberg
E
,
Hill
JA
.
et al
Effects of treatment on outcome in mildly symptomatic patients with ischemia during daily life. The Atenolol Silent Ischemia Study (ASIST).
Circulation
1994
90
762
8
PubMed
CrossRef

PubMed
Davies
RF
,
Goldberg
AD
,
Forman
S
,
Pepine
CJ
,
Knatterud
GL
,
Geller
N
.
et al
Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization.
Circulation
1997
95
2037
43
PubMed
CrossRef

PubMed
Rubenstein
LZ
,
Greenfield
S
.
The baseline ECG in the evaluation of acute cardiac complaints.
JAMA
1980
244
2536
9
PubMed
CrossRef

PubMed
Hoffman
JR
,
Igarashi
E
.
Influence of electrocardiographic findings on admission decisions in patients with acute chest pain.
Am J Med
1985
79
699
707
PubMed
CrossRef

PubMed
Hillis
LD
,
Smith
PK
,
Anderson
JL
,
Bittl
JA
,
Bridges
CR
,
Byrne
JG
.
et al
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Thorac Cardiovasc Surg
2012
143
4
34
PubMed
CrossRef

PubMed
Yusuf
S
,
Zucker
D
,
Peduzzi
P
,
Fisher
LD
,
Takaro
T
,
Kennedy
JW
.
et al
Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration.
Lancet
1994
344
563
70
PubMed
CrossRef

PubMed
Chaitman
BR
,
Bourassa
MG
,
Davis
K
,
Rogers
WJ
,
Tyras
DH
,
Berger
R
.
et al
Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS).
Circulation
1981
64
360
7
PubMed
CrossRef

PubMed
Boden
WE
,
O'Rourke
RA
,
Teo
KK
,
Hartigan
PM
,
Maron
DJ
,
Kostuk
WJ
.
et al
COURAGE Trial Research Group
Optimal medical therapy with or without PCI for stable coronary disease.
N Engl J Med
2007
356
1503
16
PubMed
CrossRef

PubMed
Hollenberg
M
,
Zoltick
JM
,
Go
M
,
Yaney
SF
,
Daniels
W
,
Davis
RC
Jr
.
et al
Comparison of a quantitative treadmill exercise score with standard electrocardiographic criteria in screening asymptomatic young men for coronary artery disease.
N Engl J Med
1985
313
600
6
PubMed
CrossRef

PubMed
Myers
J
,
Arena
R
,
Franklin
B
,
Pina
I
,
Kraus
WE
,
McInnis
K
.
et al
American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention of the Council on Clinical Cardiology
the Council on Nutrition, Physical Activity, and Metabolism, and the Council on Cardiovascular Nursing
Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association.
Circulation
2009
119
3144
61
PubMed
CrossRef

PubMed
Ranhosky
A
,
Kempthorne-Rawson
J
.
The safety of intravenous dipyridamole thallium myocardial perfusion imaging. Intravenous Dipyridamole Thallium Imaging Study Group.
Circulation
1990
81
1205
9
PubMed
CrossRef

PubMed
Lattanzi
F
,
Picano
E
,
Adamo
E
,
Varga
A
.
Dobutamine stress echocardiography: safety in diagnosing coronary artery disease.
Drug Saf
2000
22
251
62
PubMed
CrossRef

PubMed
Fazel
R
,
Krumholz
HM
,
Wang
Y
,
Ross
JS
,
Chen
J
,
Ting
HH
.
et al
Exposure to low-dose ionizing radiation from medical imaging procedures.
N Engl J Med
2009
361
849
57
PubMed
CrossRef

PubMed
Cerqueira
MD
,
Allman
KC
,
Ficaro
EP
,
Hansen
CL
,
Nichols
KJ
,
Thompson
RC
.
et al
Recommendations for reducing radiation exposure in myocardial perfusion imaging.
J Nucl Cardiol
2010
17
709
18
PubMed
CrossRef

PubMed
Berrington de Gonzalez
A
,
Kim
KP
,
Smith-Bindman
R
,
McAreavey
D
.
Myocardial perfusion scans: projected population cancer risks from current levels of use in the United States.
Circulation
2010
122
2403
10
PubMed
CrossRef

PubMed
Banerjee
A
,
Newman
DR
,
Van den Bruel
A
,
Heneghan
C
.
Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies.
Int J Clin Pract
2012
66
477
92
PubMed
CrossRef

PubMed
Uhl
GS
,
Froelicher
V
.
Screening for asymptomatic coronary artery disease.
J Am Coll Cardiol
1983
1
946
55
PubMed
CrossRef

PubMed
Mahajan
N
,
Polavaram
L
,
Vankayala
H
,
Ference
B
,
Wang
Y
,
Ager
J
.
et al
Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis.
Heart
2010
96
956
66
PubMed
CrossRef

PubMed
Fleischmann
KE
,
Hunink
MG
,
Kuntz
KM
,
Douglas
PS
.
Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance.
JAMA
1998
280
913
20
PubMed
CrossRef

PubMed
Aktas
MK
,
Ozduran
V
,
Pothier
CE
,
Lang
R
,
Lauer
MS
.
Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program.
JAMA
2004
292
1462
8
PubMed
CrossRef

PubMed
Cournot
M
,
Taraszkiewicz
D
,
Galinier
M
,
Chamontin
B
,
Boccalon
H
,
Hanaire-Broutin
H
.
et al
Is exercise testing useful to improve the prediction of coronary events in asymptomatic subjects?
Eur J Cardiovasc Prev Rehabil
2006
13
37
44
PubMed
CrossRef

PubMed
Chan
PS
,
Patel
MR
,
Klein
LW
,
Krone
RJ
,
Dehmer
GJ
,
Kennedy
K
.
et al
Appropriateness of percutaneous coronary intervention.
JAMA
2011
306
53
61
PubMed
PubMed
de Bono
D
.
Complications of diagnostic cardiac catheterisation: results from 34,041 patients in the United Kingdom confidential enquiry into cardiac catheter complications. The Joint Audit Committee of the British Cardiac Society and Royal College of Physicians of London.
Br Heart J
1993
70
297
300
PubMed
CrossRef

PubMed
Kale
MS
,
Bishop
TF
,
Federman
AD
,
Keyhani
S
.
Trends in the overuse of ambulatory health care services in the United States.
JAMA Intern Med
2013
173
142
8
PubMed
CrossRef

PubMed
Korenstein
D
,
Falk
R
,
Howell
EA
,
Bishop
T
,
Keyhani
S
.
Overuse of health care services in the United States: an understudied problem.
Arch Intern Med
2012
172
171
8
PubMed
CrossRef

PubMed
Schwartz
A
,
Amidon
P
,
Avitzur
O
,
Begley
K
,
Byrne
S
,
Benatar
G
.
et al
Heart Disease Prevention Survey.
Yonkers, NY
Consumer Reports National Research Center
2010
Hendel
RC
,
Cerqueira
M
,
Douglas
PS
,
Caruth
KC
,
Allen
JM
,
Jensen
NC
.
et al
A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria.
J Am Coll Cardiol
2010
55
156
62
PubMed
CrossRef

PubMed
Gibbons
RJ
,
Miller
TD
,
Hodge
D
,
Urban
L
,
Araoz
PA
,
Pellikka
P
.
et al
Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center.
J Am Coll Cardiol
2008
51
1283
9
PubMed
CrossRef

PubMed
Winchester
DE
,
Meral
R
,
Ryals
S
,
Beyth
RJ
,
Shaw
LJ
.
Appropriate use of myocardial perfusion imaging in a veteran population: profit motives and professional liability concerns [Letter].
JAMA Intern Med
2013
173
1381
3
PubMed
CrossRef

PubMed
Kravitz
RL
,
Callahan
EJ
.
Patients' perceptions of omitted examinations and tests: a qualitative analysis.
J Gen Intern Med
2000
15
38
45
PubMed
CrossRef

PubMed
Levin
DC
,
Rao
VM
,
Parker
L
,
Frangos
AJ
,
Intenzo
CM
.
Recent payment and utilization trends in radionuclide myocardial perfusion imaging: comparison between self-referral and referral to radiologists.
J Am Coll Radiol
2009
6
437
41
PubMed
CrossRef

PubMed
Shah
BR
,
Cowper
PA
,
O'Brien
SM
,
Jensen
N
,
Patel
MR
,
Douglas
PS
.
et al
Association between physician billing and cardiac stress testing patterns following coronary revascularization.
JAMA
2011
306
1993
2000
PubMed
CrossRef

PubMed
Hudson
B
,
Zarifeh
A
,
Young
L
,
Wells
JE
.
Patients' expectations of screening and preventive treatments.
Ann Fam Med
2012
10
495
502
PubMed
CrossRef

PubMed
Woolf
SH
.
The price of false beliefs: unrealistic expectations as a contributor to the health care crisis [Editorial].
Ann Fam Med
2012
10
491
4
PubMed
CrossRef

PubMed
Schwartz
LM
,
Woloshin
S
,
Fowler
FJ
Jr
,
Welch
HG
.
Enthusiasm for cancer screening in the United States.
JAMA
2004
291
71
8
PubMed
CrossRef

PubMed
Wilson
IB
,
Dukes
K
,
Greenfield
S
,
Kaplan
S
,
Hillman
B
.
Patients' role in the use of radiology testing for common office practice complaints.
Arch Intern Med
2001
161
256
63
PubMed
CrossRef

PubMed
Lovett
KM
,
Liang
BA
.
Direct-to-consumer cardiac screening and suspect risk evaluation.
JAMA
2011
305
2567
8
PubMed
CrossRef

PubMed
Carrier
ER
,
Reschovsky
JD
,
Katz
DA
,
Mello
MM
.
High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice.
Health Aff (Millwood)
2013
32
1383
91
PubMed
CrossRef

PubMed
Studdert
DM
,
Mello
MM
,
Sage
WM
,
DesRoches
CM
,
Peugh
J
,
Zapert
K
.
et al
Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.
JAMA
2005
293
2609
17
PubMed
CrossRef

PubMed
Matheny
M
,
McPheeters
ML
,
Glasser
A
,
Mercaldo
N
,
Weaver
RB
,
Jerome
RN
.
et al
Systematic Review of Cardiovascular Disease Risk Assessment Tools. Evidence syntheses/technology assessments, no. 85.
Rockville, MD
Agency for Healthcare Research and Quality
2011
Ferket
BS
,
Genders
TS
,
Colkesen
EB
,
Visser
JJ
,
Spronk
S
,
Steyerberg
EW
.
et al
Systematic review of guidelines on imaging of asymptomatic coronary artery disease.
J Am Coll Cardiol
2011
57
1591
600
PubMed
CrossRef

PubMed
Young
LH
,
Wackers
FJ
,
Chyun
DA
,
Davey
JA
,
Barrett
EJ
,
Taillefer
R
.
et al
DIAD Investigators
Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial.
JAMA
2009
301
1547
55
PubMed
CrossRef

PubMed
Galper
BZ
,
Moran
A
,
Coxson
PG
,
Pletcher
MJ
,
Heidenreich
P
,
Lazar
LD
.
et al
Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis.
Circulation
2012
125
260
70
PubMed
CrossRef

PubMed
Patel
MR
,
Dehmer
GJ
,
Hirshfeld
JW
,
Smith
PK
,
Spertus
JA
.
American College of Cardiology Foundation Appropriateness Criteria Task Force
ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography.
J Am Coll Cardiol
2009
53
530
53
PubMed
CrossRef

PubMed
Iglehart
JK
.
Health insurers and medical-imaging policy—a work in progress.
N Engl J Med
2009
360
1030
7
PubMed
CrossRef

PubMed
Medicare Payment Advisory Commission
Report to the Congress: Improving Incentives in the Medicare Program.
Washington, DC
Medicare Payment Advisory Commission
2009
Lockwood
CM
.
Direct-to-consumer cardiac screening tests: user beware.
Clin Chem
2012
58
1068
9
PubMed
CrossRef

PubMed
Gibbons
RJ
,
Askew
JW
,
Hodge
D
,
Kaping
B
,
Carryer
DJ
,
Miller
T
.
Appropriate use criteria for stress single-photon emission computed tomography sestamibi studies: a quality improvement project.
Circulation
2011
123
499
503
PubMed
CrossRef

PubMed
Grimshaw
JM
,
Shirran
L
,
Thomas
R
,
Mowatt
G
,
Fraser
C
,
Bero
L
.
et al
Changing provider behavior: an overview of systematic reviews of interventions.
Med Care
2001
39
II2
45
PubMed
CrossRef

PubMed
Neilson
EG
,
Johnson
KB
,
Rosenbloom
ST
,
Dupont
WD
,
Talbert
D
,
Giuse
DA
.
et al
Resource Utilization Committee
The impact of peer management on test-ordering behavior.
Ann Intern Med
2004
141
196
204
CrossRef

PubMed

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2 Comments

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.
References
1.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

In response

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.

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2015 American College of Physicians

Clinical Guidelines |17 March 2015

Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians Free

Abstract

Table 1. Estimated Costs of Cardiac Screening Tests

Methods

What Are the Evidence-Based Recommendations for the Use of Cardiac Testing in Asymptomatic Adults?

Table 2. Estimated 10-y Probability of Coronary Heart Disease Based on Traditional Risk Factors

What Are the Potential Harms of Screening?

Does Practice Follow the Evidence?

What Forces Promote the Overuse of Cardiac Testing in Asymptomatic Adults?

How Can Physicians Reduce Overuse of Cardiac Testing?

Table 3. Cardiovascular Risk Calculators

Conclusion

ACP High-Value Care Advice

Figure.

References

Figure.

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

Clinical Slide Sets

This feature is available only to Registered Users

2 Comments

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Follow Annals On

Clinical Guidelines |17 March 2015

Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians Free

Abstract

Table 1. Estimated Costs of Cardiac Screening Tests

Methods

What Are the Evidence-Based Recommendations for the Use of Cardiac Testing in Asymptomatic Adults?

Table 2. Estimated 10-y Probability of Coronary Heart Disease Based on Traditional Risk Factors

What Are the Potential Harms of Screening?

Does Practice Follow the Evidence?

What Forces Promote the Overuse of Cardiac Testing in Asymptomatic Adults?

How Can Physicians Reduce Overuse of Cardiac Testing?

Table 3. Cardiovascular Risk Calculators

Conclusion

ACP High-Value Care Advice

Figure.

References

Figure.

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

Clinical Slide Sets

This feature is available only to Registered Users

2 Comments

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