In the Journals

USPSTF: ECG insufficient to screen for CVD in asymptomatic patients

The U.S. Preventive Services Task Force has issued a recommendation statement that is against the use of resting or exercise ECG to screen adults who are asymptomatic and are at low risk for CVD events.

The recommendation, published in JAMA, is an update to the 2012 USPSTF recommendation.

“As in 2012, the USPSTF continues to recommend against screening with ECG in adults at low risk, and the evidence remains insufficient on screening in adults at increased risk,” the USPSTF wrote.

Available evidence

The USPSTF determined that the evidence was inadequate to determine whether the addition of resting or exercise ECG to conventional risk factor assessment results in improved risk stratification, in addition to it guiding treatment decisions to reduce CVD events. The evidence was also inadequate that resting or exercise ECG leads to harms in adults who are asymptomatic.

“The USPSTF concludes with moderate certainty that the potential harms of screening with resting or exercise ECG to prevent CVD events equal or exceed the potential benefits in asymptomatic adults at low risk of CVD events,” the USPSTF wrote.

Clinicians who are deciding whether to screen patients who are asymptomatic with exercise or resting ECG should consider potential preventable burden, potential harms and current practice, according to the statement. Patients who are at increased risk for CVD events may have the greatest net benefit with this screening method.

“Regardless of ECG findings, persons who are already at high risk of CVD events should receive intensive risk factor modification,” the USPSTF wrote. “Persons who are classified as low risk are unlikely to benefit from screening with ECG.”

Some potential harms related to exercise or resting ECG include unnecessary radiation exposure from invasive confirmatory testing and treatment, contrast-induced nephropathy, bleeding, stroke, cardiac arrhythmia, coronary artery dissection, MI, death and allergic reaction to the contrast agent.

Clinicians should assess CVD risk with the Pooled Cohort Equations, according to the statement.

Further research

Several studies have reported HRs and other links between ECG changes and CV outcomes, although more research is needed to assess the value of adding ECG to risk assessment tools to inform decision-making. Additional further research also includes patient outcomes, the value of ECG on clinically relevant risk thresholds and harms linked to ECG assessment.

“Treatment to prevent CVD events by modifying risk factors is currently informed by CVD risk assessment with tools such as the Framingham Risk Score or the Pooled Cohort Equations, which stratify individual risk to inform treatment decisions,” the USPSTF wrote. “If existing CVD risk assessment tools could be improved, treatment might be better targeted, thereby maximizing the benefits of and minimizing the harms of screening.”

Joseph Alpert, MD
Joseph S. Alpert

In a related editorial, Robert J. Myerburg, MD, professor of medicine in the division of cardiology at University of Miami Miller School of Medicine, wrote: “Future research is needed on the topic of resting and exercise ECG markers of risk, for both coronary atherosclerosis and other cardiac diseases, and for clarification of normal ECG variants in special populations such as athletes. As new knowledge about the subtleties of risk and risk prediction emerge from future research, re-evaluation of the potential value of these procedures may lead to appropriate reclassification of risk. The sciences contributing to medical practice are dynamic, and today’s valid conclusions may be modified by future information.”

Other physicians agreed with the recommendations that discourage physicians from using these tests to screen asymptomatic patients.

“The resting and exercise ECG are useful diagnostic tools that can easily disclose important clinical information in an inpatient or outpatient setting,” Joseph S. Alpert, MD, professor of medicine at the University of Arizona Sarver Heart Center in Tucson and Cardiology Today Editorial Board Member, wrote in a related editorial published in JAMA Cardiology. “Both forms of ECG are inexpensive and may contain diagnostic or prognostic findings. As pointed out by the USPSTF recommendations, the resting or the exercise ECG test is not useful, nor should it be touted, as a screening test for predicting outcomes in asymptomatic individuals without CVD.” – by Darlene Dobkowski

Disclosure s : Members of the USPSTF report receiving travel reimbursement and honoraria for participating in USPSTF meetings. Alpert and Myerburg report no relevant financial disclosures.

The U.S. Preventive Services Task Force has issued a recommendation statement that is against the use of resting or exercise ECG to screen adults who are asymptomatic and are at low risk for CVD events.

The recommendation, published in JAMA, is an update to the 2012 USPSTF recommendation.

“As in 2012, the USPSTF continues to recommend against screening with ECG in adults at low risk, and the evidence remains insufficient on screening in adults at increased risk,” the USPSTF wrote.

Available evidence

The USPSTF determined that the evidence was inadequate to determine whether the addition of resting or exercise ECG to conventional risk factor assessment results in improved risk stratification, in addition to it guiding treatment decisions to reduce CVD events. The evidence was also inadequate that resting or exercise ECG leads to harms in adults who are asymptomatic.

“The USPSTF concludes with moderate certainty that the potential harms of screening with resting or exercise ECG to prevent CVD events equal or exceed the potential benefits in asymptomatic adults at low risk of CVD events,” the USPSTF wrote.

Clinicians who are deciding whether to screen patients who are asymptomatic with exercise or resting ECG should consider potential preventable burden, potential harms and current practice, according to the statement. Patients who are at increased risk for CVD events may have the greatest net benefit with this screening method.

“Regardless of ECG findings, persons who are already at high risk of CVD events should receive intensive risk factor modification,” the USPSTF wrote. “Persons who are classified as low risk are unlikely to benefit from screening with ECG.”

Some potential harms related to exercise or resting ECG include unnecessary radiation exposure from invasive confirmatory testing and treatment, contrast-induced nephropathy, bleeding, stroke, cardiac arrhythmia, coronary artery dissection, MI, death and allergic reaction to the contrast agent.

Clinicians should assess CVD risk with the Pooled Cohort Equations, according to the statement.

Further research

Several studies have reported HRs and other links between ECG changes and CV outcomes, although more research is needed to assess the value of adding ECG to risk assessment tools to inform decision-making. Additional further research also includes patient outcomes, the value of ECG on clinically relevant risk thresholds and harms linked to ECG assessment.

“Treatment to prevent CVD events by modifying risk factors is currently informed by CVD risk assessment with tools such as the Framingham Risk Score or the Pooled Cohort Equations, which stratify individual risk to inform treatment decisions,” the USPSTF wrote. “If existing CVD risk assessment tools could be improved, treatment might be better targeted, thereby maximizing the benefits of and minimizing the harms of screening.”

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Joseph Alpert, MD
Joseph S. Alpert

In a related editorial, Robert J. Myerburg, MD, professor of medicine in the division of cardiology at University of Miami Miller School of Medicine, wrote: “Future research is needed on the topic of resting and exercise ECG markers of risk, for both coronary atherosclerosis and other cardiac diseases, and for clarification of normal ECG variants in special populations such as athletes. As new knowledge about the subtleties of risk and risk prediction emerge from future research, re-evaluation of the potential value of these procedures may lead to appropriate reclassification of risk. The sciences contributing to medical practice are dynamic, and today’s valid conclusions may be modified by future information.”

Other physicians agreed with the recommendations that discourage physicians from using these tests to screen asymptomatic patients.

“The resting and exercise ECG are useful diagnostic tools that can easily disclose important clinical information in an inpatient or outpatient setting,” Joseph S. Alpert, MD, professor of medicine at the University of Arizona Sarver Heart Center in Tucson and Cardiology Today Editorial Board Member, wrote in a related editorial published in JAMA Cardiology. “Both forms of ECG are inexpensive and may contain diagnostic or prognostic findings. As pointed out by the USPSTF recommendations, the resting or the exercise ECG test is not useful, nor should it be touted, as a screening test for predicting outcomes in asymptomatic individuals without CVD.” – by Darlene Dobkowski

Disclosure s : Members of the USPSTF report receiving travel reimbursement and honoraria for participating in USPSTF meetings. Alpert and Myerburg report no relevant financial disclosures.