ECG Screening Still Bad Idea in Low-CV-Risk Asymptomatic Patients: New USPSTF Statement

June 12, 2018

In a rare endorsement of clinical inertia, a new US Preventive Services Task Force (USPSTF) statement gives nearly the same recommendations on electrocardiography (ECG) screening for asymptomatic adults as those it published 6 years ago.

Resting or exercise screening ECG should be avoided in asymptomatic adults considered to be at low risk for cardiovascular (CV) events, the USPSTF said, noting it found "adequate evidence" that it "leads to harms that are at least small and may be moderate."

The USPSTF further concluded that there is insufficient benefit-vs-harm evidence to recommend whether resting or exercise screening ECG testing should be performed in asymptomatic adults judged to be at intermediate or high CV risk.

The resting ECG "has the potential for anxiety and labeling; however, the USPSTF was unable to find relevant studies on these harms. Exercise ECG has more potential for direct harms (eg, triggering a cardiovascular event or musculoskeletal injury), but survey data of symptomatic patients suggests that these harms are very rare," the statement says.

"The primary concern for both types of ECG screening is the harm of subsequent procedures or interventions initiated as a result of screening (eg, angiography or revascularization procedures)."

The statement was published today in JAMA with an accompanying report documenting the methods and results of the literature searches on which it is based.

That evidence report, with lead author Daniel E. Jonas, MD, MPH, University of North Carolina at Chapel Hill, said the new recommendations are based on 16 studies with a combined enrollment of 77,140.

The new document is not substantially different from a draft version released in December 2017 that was open to public comment. It's also very similar to the task force's corresponding statement from 2012, even with consideration of clinical trial evidence published in the interim.

The USPSTF recommendations, especially for low-risk patients, are also largely consistent with those from more than a few medical societies, including the American College of Cardiology, the American College of Physicians, and the American College of Preventive Medicine.

Nondueling Editorials

Three editorials on the new statement were simultaneously published in JAMA and two other publications under the flagship journal's umbrella.

The USPSTF statement regarding intermediate- and high-risk patients recognizes that "this group should not be viewed as a uniform dichotomy compared with the low-risk group, but rather as having a gradient of risk based on the number and intensity of risk factors contributing to the scoring models," writes Robert J. Myerburg, MD, University of Miami Miller School of Medicine, Florida, in his JAMA editorial .

"The indeterminate conclusion again defers to the judgement of the practicing physicians, with the implication of using the individual risk data to guide their decisions for added testing in general and ECGs in particular."

Editorialists in JAMA Internal Medicine note that even with the USPSTF conclusion of insufficient evidence in intermediate- and high-risk adults, the value that a screening ECG adds to accepted risk stratification measures "is likely marginal."

In such cases, "the incremental value of the ECG findings would likely not be reclassification of CVD risk, but rather the detection of flow-limiting coronary artery disease for the purpose of revascularization," write R. Sacha Bhatia, MD, MBA, and Paul Dorian, MD, MSc, both from the University of Toronto, Ontario, Canada. But in asymptomatic adults, "revascularization does not lead to improved cardiovascular outcomes compared with medical therapy."

Practice Falls Behind Consensus

Whereas the exercise ECG has important uses in patients "who present with chest discomfort, dyspnea, or palpitations," neither the resting nor exercise version of the test is a useful supplement to routine risk assessment in the "otherwise healthy asymptomatic individual," Joseph S. Alpert, MD, University of Arizona College of Medicine, Tucson, says in an editorial in JAMA Cardiology .

"Yet, many ECGs are ordered yearly on otherwise healthy adults," he writes.

Alpert says despite his general agreement with the USPSTF statement, he "finds it curious, because in more than 40 years as an internist/cardiologist, I had never heard anyone overtly state: screening asymptomatic individuals with a resting or exercise ECG would be of use in predicting CV-disease events and thereby help to prevent such events and improve clinical outcomes."

But, he notes, "the ECG is ubiquitous and often obtained unconsciously as part of a routine physical examination, and it is possible that many clinicians order these tests with the mistaken impression that the information in the ECG will be useful in preventing future cardiovascular events."

The USPSTF statement says all its members received travel reimbursement and honoraria for participating in USPSTF meetings; no other disclosures were reported. No conflicts of interest were reported by authors of the evidence report, nor by Myerburg or Alpert. Bhatia and Dorian had no relevant disclosures.

JAMA. Published online June 12, 2018. USPSTF statement, USPSTF evidence report, Myerburg editorial

JAMA Intern Med. Published online June 12, 2018. Bhatia editorial

JAMA Cardiol. Published online June 12, 2018.  Alpert editorial

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