On June 12, the U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement(www.uspreventiveservicestaskforce.org) and final evidence summary(www.uspreventiveservicestaskforce.org) on screening for cardiovascular disease (CVD) risk with electrocardiography (ECG).
Based on its review of the evidence, the USPSTF recommended against screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at low risk for such events -- a "D" recommendation.(www.uspreventiveservicestaskforce.org)
The task force noted that treatment to prevent CVD events through risk factor modification is currently informed by CVD risk assessment tools such as the Framingham Risk Score and the Pooled Cohort Equations. These tools stratify individual risk based on factors such as age, race/ethnicity, gender, obesity, diabetes, smoking status, cholesterol levels and blood pressure.
"Adding ECG screening for people at low risk of a heart attack or stroke is unlikely to help prevent CVD events and can actually cause harms from subsequent procedures such as angiograms," said USPSTF member Seth Landefeld, M.D., in a news release.(www.uspreventiveservicestaskforce.org)
- On June 12, the U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement and final evidence summary on screening for cardiovascular disease (CVD) risk with electrocardiography (ECG).
- Based on its review of the evidence, the USPSTF recommended against screening with resting or exercise ECG to prevent CVD events in low-risk, asymptomatic adults -- a "D" recommendation.
- The USPSTF also found insufficient evidence to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk for such events -- an "I" recommendation.
Landefeld added that physicians should address any concerns that patients may have about their risk for heart disease, heart attack or stroke.
The USPSTF also found insufficient evidence to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk for such events -- an "I" recommendation.
"There is not enough evidence for those who might benefit the most -- people at higher risk for CVD -- to say if adding ECG screening helps prevent heart attack and stroke," said USPSTF member Michael Barry, M.D., in the release. "Clinicians should continue to use traditional risk factors to assess CVD risk and guide treatment for these patients until more evidence is available."
Although the task force was unable to identify any studies that directly assessed whether adding resting ECG to current CVD risk assessment improves cardiovascular outcomes for any risk group, it did find two fair-quality randomized, controlled trials of screening with exercise ECG in patients with diabetes that showed no difference in mortality or cardiovascular events. Both trials fell far short of their intended enrollment numbers, however, and therefore were underpowered to detect a difference in cardiovascular outcomes within a relatively short time period (mean of 3.5 years), the recommendation statement noted.
This final recommendation statement is consistent with the USPSTF's December 2017 draft recommendation statement and its 2013 final recommendation statement,(www.uspreventiveservicestaskforce.org) which the AAFP agreed with at the time.
Response to Public Comment/More Research Needed
A draft version of the final recommendation statement was available for public comment from Dec. 19, 2017, to Jan. 22.
In response to some commenters, the USPSTF clarified the definition of CVD as encompassing atherosclerotic conditions such as coronary heart disease, cerebrovascular disease and peripheral arterial disease.
The task force also addressed requests from other commenters by recommending Pooled Cohort Equations as its preferred CVD risk assessment tool.
As for research gaps, the USPSTF said studies are still needed to assess the incremental value of adding ECG to current CVD risk assessment tools or instruments to directly inform decision-making, with studies that examine patient outcomes being most useful.
Additionally, the task force said research that assesses the added value of ECG for risk reclassification across clinically relevant risk thresholds is also needed. And any study of CVD risk assessment should include an evaluation of the harms associated with assessment, as well as those related to additional testing and treatment.
Finally, the USPSTF said studies that measure risk reclassification should report total, event and nonevent Net Reclassification Indices, with corresponding confidence intervals, as well as measures of calibration and discrimination.
The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statement and evidence review and determine the Academy's stance on the recommendation.
Related AAFP News Coverage
USPSTF Examines ECG Screening to Prevent CVD Events, AFib
Lack of Evidence Precludes Recommendations for Many Adults