ACP releases High Value Care advice for one of the most common diagnostic tests in US

Physicians should not screen for cardiac disease in adults at low risk for coronary heart disease (CHD) with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging, the American College of Physicians (ACP) advises in a paper published today in Annals of Internal Medicine.

"Cardiac screening in adults at low risk for coronary heart disease is low value care because it does not improve patient outcomes and it can lead to potential harms," said Dr. David Fleming, president, ACP. "Physicians should instead focus on strategies for improving cardiovascular health by treating modifiable risk factors such as smoking, diabetes, hypertension, high cholesterol, obesity, and encouraging healthy levels of exercise."

Authored for ACP's High Value Care Task Force by Dr. Roger Chou, "Cardiac Screening with Electrocardiogram, Stress Echocardiography, or Myocardial Perfusion Imaging" aims to provide physicians with practical advice based on the best available evidence.

Although CHD the single leading cause of death in the United States, the benefits of cardiac screening in low-risk adults have long been questioned, Dr. Chou writes. Despite potential harms and insufficient evidence of benefits, cardiac screening tests are still frequently obtained in clinical practice—and perhaps increasing. Electrocardiography is among the most commonly performed diagnostic tests in the United States.

The paper notes several factors that may contribute to inappropriate cardiac screening of low-risk adults, including patient expectations, commercial screening programs, financial incentives, concerns about malpractice liability, and overestimating the benefits and underestimating the harms of screening.

"The limited data suggest that even 'baseline' ECGs are rarely helpful," Dr. Fleming said. "It is easy to overlook false positives as potential harms, for example, but they may result in unnecessary tests and treatments with their own additional risks, and the harms of radiation exposure may not be seen for years."

Rather than screening low risk adults for CHD, physicians should start a cardiovascular risk assessment with a global risk score that combines individual risk factor measurements into a single quantitative estimate of risk. Patients in the low risk category should not be screened with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

ACP's advice does not pertain to patients with symptoms or to athletes for pre-participation screening.

A summary for patients was also published in Annals.