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ACP advises against CHD screening in low-risk patients
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High-Value Care Advice issued by the American College of Physicians recommends against screening for cardiac disease among asymptomatic, low-risk adults, according to a guideline published in the Annals of Internal Medicine.
“Cardiac screening in adults at low risk for CHD is low-value care because it does not improve patient outcomes and it can lead to potential harms,” David Fleming, MD, American College of Physicians (ACP) president, said in a press release. “Physicians should instead focus on strategies for improving CV health by treating modifiable risk factors such as smoking, diabetes, hypertension, high cholesterol, obesity and encouraging healthy levels of exercise.”
David Fleming
The paper, written by Roger Chou, MD, on behalf of the ACP High Value Care Task Force, utilized data from a systematic review and recommendations from the U.S. Preventive Services Task Force (USPSTF) on screening with ECG, along with guidelines and standards developed by the American College of Cardiology in conjunction with other medical societies, and articles on cardiac screening.
Chou wrote that although CHD is the leading cause of death in the United States, the benefits of cardiac screening in low-risk adults have been called into question. The USPSTF, he wrote, recommends against ECG screening in this patient population, along with the ACC and the American Heart Association. Despite these recommendations, use of cardiac screening remains frequent and may be increasing: The paper cited results from a systematic review that reported overuse rates of 9.2% for ECG and a range of 3% to 52% for cardiac stress tests. Results from a Consumer Reports survey indicated that 39% of asymptomatic adults without high BP or high cholesterol had undergone ECG within the past 5 years, whereas 12% reported exercise ECG. More than half of these patients indicated that these screening tests were recommended by their doctors as part of routine care, Chou wrote.
Roger Chou
According to Chou, factors that potentially contribute to this observed overuse of cardiac screening include patient enthusiasm for screening, commercial availability of direct-to-consumer screening programs, financial incentives, practicing of “defensive medicine” due to concerns about malpractice liability and clinicians’ overestimation of the benefits and underestimation of the potential harms of screening.
Although possible harmful effects such as sudden death or hospitalization, or adverse events from pharmacologic agents administered to induce stress during stress testing, are infrequent, other factors such as radiation exposure due to myocardial perfusion imaging and downstream effects due to follow-up tests and interventions can occur. He also noted that false-positive results can lead to the performance of unnecessary additional tests and procedures.
“Health care practices associated with high costs and limited or no benefits provide little value,” Chou wrote. “There is no evidence that cardiac screening of low-risk adults with resting or stress ECG, stress echocardiography or stress [myocardial perfusion imaging] improves patient outcomes, but it is associated with increased costs and potential harms.” He called for recommendations supporting the use of traditional CV risk factors and a global risk score when performing initial CV risk assessment, as well as a “multifocal” effort to reduce imaging use that addresses the behavior of both clinicians and patients.
Disclosures: Chou reports receiving grants from the ACP while conducting the study, as well as grants from the Agency for Healthcare Research and Quality outside of the submitted work. One member of the ACP High Value Care Task Force reported serving as the chair of the ACP Board of Governors for 2014-2015, and another reported serving as a consultant for Wolters Kluwer Health outside of the submitted work.
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