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Echocardiographic screening of general public failed to lower death, MI, stroke rates
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Echocardiographic screening of the general population for structural and valvular heart disease was not associated with benefit for reducing death, MI or stroke, researchers reported in a new study.
The analysis included middle-aged participants from the population-based, prospective cohort Tromsø Study conducted in Norway. Researchers aimed to determine whether population-wide echocardiographic screening would reduce risk for CVD or enhance long-term survival.
Echocardiographic screening has typically not been considered appropriate for those at low risk, but has been considered appropriate for those without symptoms who have a family history of CVD or sudden death, according to background information in the study.
The study did not begin as a randomized trial, but became one on the participants’ second visit with investigators. At that point, participants were randomly assigned to echocardiographic screening (n=3,272) or a control group (n=3,589). The screening group was examined with a cardiac ultrasonography system (CFM 750, VingMed Sound A/S) with a combined 3.25-MHz mechanical and 2.5-MHz Doppler probe. Researchers analyzed the data using the as-treated approach.
Two hundred ninety participants (8.9%) in the screening group underwent follow-up examinations because their screens showed abnormalities, and 249 (7.6%) were confirmed to have cardiac or valvular conditions.
The primary outcome was death from all causes. Participants were followed for 15 years. During that time, 880 (26.9%) in the screening group died compared with 989 (27.6%) in the control group (HR=0.97; 95% CI, 0.89-1.06).
Secondary outcomes of interest included sudden death, death from heart disease, fatal/nonfatal MI and fatal/nonfatal stroke. Researchers reported similar results between the groups for secondary outcomes: sudden death (HR=0.97; 95% CI, 0.51-0.87), death from heart disease (HR=0.91; 95% CI, 0.77-1.08), fatal/nonfatal MI (HR=0.95; 95% CI, 0.83-1.08), fatal/nonfatal stroke (HR=1.02; 95% CI, 0.87-1.19).
“The importance of our findings is that they add empirical evidence to a recommendation based on an expert consensus opinion,” Haakon Lindekleiv, MD, PhD, of the University of Tromsø, Norway, and colleagues wrote. “Although our results are negative, we believe that they are of clinical importance because they may contribute to reducing the overuse of echocardiography.”
In an accompanying editorial, Erin D. Michos, MD, MHS, and Theodore P. Abraham, MD, both professors of cardiology at Johns Hopkins University School of Medicine, said echocardiographic screening of the general public could potentially be harmful.
“Although echocardiography is nonradiating, a normal resting echocardiogram does not exclude coronary disease,” they wrote. “Therefore, patients with a normal-appearing echocardiogram may be falsely reassured and not follow through with other recommended screening or preventive measures.”
Michos and Abraham agreed with the researchers that the findings reinforce current guidelines and could lower inappropriate use of echocardiography.
For more information:
Lindekleiv H. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.8412.
Michos ED. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.7029.
Disclosure: The researchers and editorial authors report no relevant financial disclosures.
Perspective
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Veronique L. Roger, MD, MPH
Screening assumes that early detection will lead to a more favorable outcome. This assumption is intuitively appealing, but to be appropriate for screening, a disease should be serious, treatment given before clinical symptoms should improve outcomes, and the prevalence of preclinical disease should be high in the population screened.
The study by Lindekleiv et al, published in JAMA Internal Medicine, offers the opportunity of reflecting on these principles, applied to the detection of heart disease using echocardiography. The authors screened a large number of individuals in Norway for structural heart disease. The prevalence of structural heart disease was low at 7.6% and consisted mainly of valvular heart disease for which there is no known preclinical intervention. During 15 years of follow-up, there was no detected benefit of screening, in terms of mortality from MI or stroke. These results were predictable given the principles just discussed. Further, MI is related to coronary disease, which cannot be detected by a standard resting ECG study.
Hence, based on these data, no change in the recommended standard of practice should be advocated.
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