Lown Right Care: Reducing Overuse and Underuse

Overuse of Cardiac Testing

 

Am Fam Physician. 2018 Nov 15;98(10):561-563.

Related editorial: Introducing Lown Right Care: Reducing Overuse and Underuse.

Case Scenario

A 62-year-old white man with hypertension presents for a routine physical examination. He does not smoke and has a body mass index of 32 kg per m2. After being sedentary for many years, he is about to begin an exercise program. His wife thinks he should get his heart tested before beginning to exercise. The patient does not have chest pain or pressure, dyspnea, or palpitations. His blood pressure is 125/70 mm Hg, total cholesterol is 205 mg per dL (5.31 mmol per L), low-density lipoprotein cholesterol is 118 mg per dL (3.06 mmol per L), high-density lipoprotein cholesterol is 45 mg per dL (1.17 mmol per L), and fasting glucose level is 88 mg per dL (4.9 mmol per L). Based on the American College of Cardiology and American Heart Association risk calculator (available at https://www.mdcalc.com/ascvd-atherosclerotic-cardiovascular-disease-2013-risk-calculator-aha-acc), his estimated 10-year risk of a cardiovascular event is 10.6%.

You perform electrocardiography (ECG), which shows nonspecific abnormalities, but the patient insists that you also order a stress test. A nuclear stress test shows a small area of reversible myocardial ischemia. Subsequent cardiac catheterization reveals nonobstructive coronary artery disease (CAD), for which lifestyle modifications, a moderate-intensity statin, and optimal control of blood pressure are recommended.

 Enlarge     Print

TAKE HOME MESSAGES FOR RIGHT CARE

Screening asymptomatic patients with electrocardiography has an extremely low yield in detecting significant pathology and leads to many false-positive findings.

Inappropriate cardiac stress tests, particularly with imaging, are estimated to cost the U.S. health care system as much as half a billion dollars each year and expose many patients to unnecessary radiation.

In a patient with a low pretest probability of coronary artery disease, a positive stress test is likely to be a false positive.

Coronary artery calcium scores may be helpful in determining if patients at intermediate risk of cardiovascular disease would benefit from statins.

TAKE HOME MESSAGES FOR RIGHT CARE

Screening asymptomatic patients with electrocardiography has an extremely low yield in detecting significant pathology and leads to many false-positive findings.

Inappropriate cardiac stress tests, particularly with imaging, are estimated to cost the U.S. health care system as much as half a billion dollars each year and expose many patients to unnecessary radiation.

In a patient with a low pretest probability of coronary artery disease, a positive stress test is likely to be a false positive.

Coronary artery calcium scores may be helpful in determining if patients at intermediate risk of cardiovascular disease would benefit from statins.

Clinical Commentary

Cardiovascular disease is the leading cause of death worldwide.1 More than 25% of individuals who experience acute myocardial infarction have no previous symptoms,2 making risk stratification essential to help target appropriate preventive interventions. Risk stratification should be performed using a clinical assessment of risk factors and exercise tolerance, as well as a validated risk tool. Inappropriate use of diagnostic tests to screen for cardiac disease in asymptomatic patients may lead to further testing and invasive procedures that are costly and potentially harmful, and have no clear benefits compared with clinical history and evaluation alone.

ELECTROCARDIOGRAPHY

Routine screening of asymptomatic patients with ECG has a very low yield in detecting significant pathology and leads to many false-positive findings. Performing ECG as part of a health maintenance examination does not lower the risk of future cardiovascular events or cardiac death.3 The U.S. Preventive Services Task Force (USPSTF) recommends against screening with ECG to predict CAD in low-risk patients and found insufficient evidence to assess the benefits and harms of screening in individuals at intermediate or high risk.4

STRESS TESTS

Stress ECG (exercise stress tests), stress echocardiography, and myocardial perfusion imaging are commonly used to evaluate patients for CAD. However, it is unclear if these tests add any prognostic benefit beyond a careful evaluation of underlying cardiovascular risk factors in patients without cardiac symptoms. Inappropriate

Address correspondence to Alan R. Roth, DO, at aroth@jhmc.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. World Health Organization. Cardiovascular diseases (CVDs). Fact sheet. http://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). Accessed September 23, 2018....

2. Kannel WB, Feinleib M. Natural history of angina pectoris in the Framingham study. Am J Cardiol. 1972;29(2):154–163.

3. Bhatia RS, Bouck Z, Ivers NM, et al. Electrocardiograms in low-risk patients undergoing an annual health examination. JAMA Intern Med. 2017;177(9):1326–1333.

4. U.S. Preventive Services Task Force. Cardiovascular disease risk June 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cardiovascular-disease-risk-screening-with-electrocardiography. Accessed September 11, 2018.

5. Ladopo JA, Blecker S, Douglas PS. Physician decision making and trends in the use of cardiac stress testing in the United States. Ann Intern Med. 2014;161(7):482–490.

6. Arbab-Zadeh A. Stress testing and non-invasive coronary angiography in patients with suspected coronary artery disease. Heart International. 2012;7(1):e2.

7. Princeton Longevity Center. Is your stress test the wrong test? https://princetonlongevitycenter.com/cardiac_stress_tests/. Accessed September 23, 2018.

8. 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(12):1462–1468.

9. de Bono D. Complications of 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(3):297–300.

10. Chou R, Arora B, Dana T, Fu R, Walker M, Humphrey L. Screening asymptomatic adults with resting or exercise electrocardiography. Ann Intern Med. 2011;155(6):375–385.

11. Wolk MJ, Bailey SR, Doherty JU, et al.; American College of Cardiology Foundation Appropriate Use Criteria Task Force. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol. 2014;63(4):380–406.

12. Chou R; High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging. Ann Intern Med. 2015;162(6):438–447.

13. American Academy of Family Physicians. Choosing Wisely: Annual EKGs for low-risk patients. https://www.aafp.org/patient-care/clinical-recommendations/all/cw-ekg.html. Accessed September 23, 2018.

14. Liew G, Chow C, van Pelt N, et al. Cardiac Society of Australia and New Zealand position statement: coronary artery calcium scoring. Heart Lung Circ. 2017;26(12):1239–1251.

15. U.S. Preventive Services Task Force. Final recommendation statement: cardiovascular disease: risk assessment with nontraditional risk factors. July 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cardiovascular-disease-screening-using-nontraditional-risk-assessment. Accessed September 23, 2018.

16. Sharples EJ, et al. Coronary artery calcification measured with electron-beam computerized tomography correlates poorly with coronary artery angiography in dialysis patients. Am J Kidney Dis. 2004;43(2):313–319.

17. U.S. Preventive Services Task Force. Final recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. November 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/statin-use-in-adults-preventive-medication1. Accessed September 23, 2018.

18. U.S. Preventive Services Task Force. Aspirin use to prevent cardiovascular disease and colorectal cancer: preventive medication. April 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer. Accessed September 23, 2018.

Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in Pubmed

MOST RECENT ISSUE


Dec 15, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article