New Guidelines: Heart Screening Tests Unnecessary for Low-Risk Patients

The American College of Physicians (ACP) recently issued guidelines advising against routine coronary artery disease screening for most adults who are at low risk for heart problems. The new guidelines focus on cardiac screening with electrocardiogram (EKG or ECG), a stress echocardiogram or myocardial perfusion imaging (MPI).

Screenings for low-risk adults are unlikely to give findings that will change patient management or improve patient outcomes, the guidelines say. Research shows that 90 percent of low-risk adults without symptoms will not have a cardiac event, such as a heart attack, in the 10 years post-screening. “This means that there will be few benefits, but serious potential harms from screening tests,” the guidelines say. Adults are considered low risk for coronary heart disease if they are young, without a family history of early heart disease, are physically active and eat a healthy diet.

Overused

Cardiac screening tests still are frequently obtained in clinical practice despite potential harm and insufficient evidence of benefits. Electrocardiography is among the most commonly performed diagnostic tests in the United States.

The ACP paper says several factors may contribute to inappropriate cardiac screening of low-risk adults. These include:

• patient expectations
• commercial screening programs
• financial incentives
• concerns about malpractice liability
• overestimating the benefits and underestimating the harms of screening

Appropriate use

Stress tests are best used when all information about a patient is considered, says cardiologist Curtis Rimmerman, MD. “The stress test has to be applied within the context of the patient and looking at the entire patient: their risk factor profile, their symptoms, their age and their activity level, among other information,” Dr. Rimmerman says. “In those patients who are truly low risk, oftentimes your clinical acumen can be applied very accurately and further testing really isn’t necessary.” Unnecessary stress tests can result in false-positives, Dr. Rimmerman says. That can lead to more testing, such as a heart catheterization, which can be risky and more complicated. Patient risks from the screening tests include exposure to radiation, adverse reaction to an injection, or problems during exercise, the ACP says. For patients, follow-up testing and procedures can cause anxiety and take time away from work or family. “There is a time and a place for necessary testing,” Dr. Rimmerman says. “This is a best-practice issue and, especially, an issue of what is in the best interests of the patient.”

Not routine practice

Rather than screen low-risk adults for coronary artery disease, the ACP recommends that physicians focus on promoting to their patients strategies to improve their heart health. Such strategies would include modifying patient behaviors that lead to increased risk for heart disease. These include smoking, diabetes, high blood pressure, high cholesterol and being overweight. The complete statement from the ACP appears online in the journal Annals of Internal Medicine.