Lown Right Care: Reducing Overuse and Underuse

Overuse of Cardiac Testing

Alan R. Roth, DO, FAAFP, FAAHPM; Andy Lazris, MD, CMD; Sarju Ganatra, MD,


Am Fam Physician. 2018;98(10):560 

In This Article

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.