ACP task force issues high-value care advice on cardiac screening

The High Value Care Task Force of the American College of Physicians released advice today on cardiac screening with electrocardiography, stress echocardiography, and myocardial perfusion imaging, concluding that none of these tests are warranted in asymptomatic, low-risk adults.

The Task Force's advice was based on published systematic reviews, guidelines, and articles discussing cardiac screening in low-risk adults and intended to provide practical advice supported by the best available evidence. Asymptomatic low-risk adults were defined as adults with an estimated 10-year risk for coronary heart disease (CHD) of less than 10%. Screening of children or adolescents, preparticipation screening for athletes, preoperative evaluation, evaluation of symptoms suggestive of cardiac disease, and electrocardiographic screening for drug monitoring were not addressed in the statement, which was published in the March 17 Annals of Internal Medicine.

The Task Force examined existing evidence-based recommendations for cardiac testing in asymptomatic adults, including those from the U.S. Preventive Services Task Force, and found none that support screening. Potential harms of screening include downstream harms from additional testing due to false-positive results and radiation exposure from myocardial perfusion imaging, among others. The ACP Task Force also found that clinical practice does not follow the evidence, since cardiac screening is frequently done and rates may be increasing. Overuse of such tests in asymptomatic adults may be due to clinician overestimation of the benefits of revascularization and underestimation of potential harms, an assumption that negative results will reassure patients, financial incentives, and the perceived risk of missing a critical diagnosis, the Task Force found.

The Task Force concluded that cardiac screening of low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress magnetic perfusion imaging does not improve patient outcomes but is associated with increased costs and potential harms.

“Implementing recommendations that focus on initial cardiovascular risk assessment based on traditional cardiovascular risk factors and using a global risk score, addressing modifiable risk factors, and not performing additional cardiac screening in low-risk patients would improve patient care while avoiding unnecessary harms,” the Task Force wrote. “To be most effective, efforts to reduce the use of imaging should be multifocal and should address clinician behaviors, patient expectations, direct-to-consumer screening programs, and financial incentives.”