ACP Guideline: No Cardiac Screening for Low-Risk Adults

Laurie Barclay, MD

March 16, 2015

The High Value Care Task Force of the American College of Physicians (ACP) recommends against screening for coronary heart disease (CHD) in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging. The High-Value Care advice statement by Roger Chou, MD, from Oregon Health & Science University, Portland, and colleagues was published online March 16 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," ACP President David Fleming, MD, said in a news release. "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."

In the United States, CHD is the single leading cause of death. Use of resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging for cardiac screening may identify adults at increased risk for CHD events. However, several professional societies have warned against overuse of such screening by inappropriate cardiac testing of low-risk adults, given the potential harms, high costs, and insufficient evidence of benefits.

Nonetheless, cardiac screening is still in widespread use and may be increasing, with electrocardiography among the most commonly performed diagnostic tests in the United States. Reasons for overuse may include patient expectations, commercial screening programs, financial incentives, concerns about malpractice liability, and overestimation of the benefits and underestimation of the harms of screening.

The ACP therefore reviewed recent evidence, including published systematic reviews, guidelines, and articles regarding the diagnostic performance, benefits, and potential harms of cardiac screening in low-risk adults.

Specific findings and recommendations were as follows:

  • There is no evidence that cardiac screening improves patient outcomes.

  • Potential harms of cardiac screening include false-positive results causing patients to undergo potentially unnecessary tests and procedures.

  • Among adults at low risk, prevalence of coronary heart disease is low, and cardiac screening is of low predictive value. Therefore, cardiac screening is of low yield, and the probability that positive findings will influence therapeutic decision making is low.

  • Clinicians should therefore emphasize strategies to reduce cardiovascular risk even further among low-risk adults by treating modifiable risk factors (smoking, diabetes, blood pressure, hyperlipidemia, overweight, and exercise).

  • Clinicians should not screen asymptomatic, low-risk adults for cardiac disease using resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

  • Clinicians should conduct cardiovascular risk assessment with a global risk score combining individual risk factor measurements into a single quantitative estimate of risk.

  • The ACP recommendations do not apply to symptomatic patients or to screening athletes before participation in various events.

"The limited data suggest that even 'baseline' [electrocardiograms] 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."

The ACP operating budget provided financial support for the development of this guideline. Three of the guidelines authors have financial disclosures involving the ACP, the Agency for Healthcare Research and Quality, and/or Wolters Kluwer Health.

Ann Intern Med. Published online March 16, 2015.


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