High-value Task Force: 'Just Say No' to routine heart tests

Heart skips a beatThe educational outreach program for physicians called High Value, Cost-Conscious Care of the American College of Physicians (the board which oversees policy for general internists in the U.S.) began in 2011. They have made numerous recommendations for reducing overuse of tests and procedures that they have determined are not worth doing, in terms of cost-benefit and yield in terms of improving health outcomes.

In the latest issue of the ACP s journal, The Annals of Internal Medicine, this panel reviewed the body of evidence concerning the risks and benefits of screening healthy adults for heart disease using commonly done tests, including EKGs, stress tests, and coronary perfusion studies.

The lead author of the multi-center group was Dr. Roger Chou of the Oregon Health & Science University, Portland, Oregon. Their report came to the following overall conclusions: Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging. There is no evidence that cardiac screening of low-risk adults with resting or stress ECG, stress echocardiography, or stress MPI (myocardial perfusion imaging) improves patient outcomes, but it 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 and costs.

In other words, patients with no symptoms of CAD (coronary artery disease: angina, chest pain on exertion, irregular heartbeats, shortness of breath on exertion, among others) should not be screened for heart trouble, as the predictive power of these common tests is not strong enough to outweigh the harms from false positive tests. Instead, clinicians should, in this patient population, focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.

ACSH s Dr. Gil Ross, who practiced internal medicine for two decades, had this comment: This report will come as something of a shock to many people, and even many doctors. It is quite routine, one might say expected, that patients of middle-age or older, visiting the doctor occasionally, will get a routine EKG. Many will request a more sophisticated heart work-up, including an exercise stress test. Despite the clear evidence-based conclusion of the High-Value panel, it will be difficult for many doctors to refuse such requests. Many will not take the time to explain why the patient does not need, nor even benefit, from that yearly EKG, for several reasons: 1--already mentioned, the time it takes (it takes 2 minutes for a nurse to actually do the EKG, and 1 minute for an experienced doc to read it); 2--there is reimbursement for #1 above; 3--the patient may well seek another provider who is less reluctant to just do the test: thereby the doctor will lose the patient; 4--defensive medicine: what if, god forbid, the EKG not done is evidence in a malpractice case when that patient has an unpredictable cardiac event?