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American College of Physicians advises not to screen for
cardiac disease in adults at low risk for coronary heart
Philadelphia, March 17, 2015 -- 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
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
"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
ACP's advice does not pertain to patients with symptoms or to
athletes for pre-participation screening.
for patients was also published in Annals.
About ACP's High Value Care Task ForceACP's High Value
Care initiative is designed to help doctors and patients
understand the benefits, harms, and costs of tests and treatment
options for common clinical issues so they can pursue care together
that improves health, avoids harms, and eliminates wasteful
practices. ACP defines High Value Care as the delivery of services
providing benefits that make their harms and costs worthwhile.
ACP's High Value Care Task Force papers focus on value by
evaluating the benefits, harms, and costs of a test or
intervention. Value is not merely cost. Some expensive tests and
treatments have high value because they provide high benefit and
low harm. Conversely, some inexpensive tests or treatments have low
value because they do not provide enough benefit to justify even
their low costs and might even be harmful.
About the American College of Physicians
The American College of Physicians is the largest
medical specialty organization and the second-largest physician
group in the United States. ACP members include 141,000 internal
medicine physicians (internists), related subspecialists, and
medical students. Internal medicine physicians are specialists who
apply scientific knowledge and clinical expertise to the diagnosis,
treatment, and compassionate care of adults across the spectrum
from health to complex illness. Follow ACP on Twitter and Facebook.