Annual EKGs for Low-risk Patients

Recommendation

Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

• There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low-risk for coronary heart disease improves health outcomes.
• False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis.
• Potential harms of this routine annual screening exceed the potential benefit.

_{Sources: US Preventive Services Task Force (USPSTF)}

Supporting Information

Recent guidelines from the U.S. Preventive Services Task Force (USPSTF) (2011), the American Academy of Family Physicians (AAFP) (2011), the American College of Cardiology (ACC) Foundation (2010), and the American Heart Association (AHA) (2010) advise against exercise electrography in asymptomatic, low-risk individuals.

The AHA compiled data, including information from the Framingham Heart Study, to determine appropriate use of cardiac screening tests by looking at prognostic considerations. Those risk factors include gender and age (males over the age of 45 years) with one or more risk factors. The greater the number of risk factors a patient has, the more likely it is that the patient will benefit from screening. If a patient’s risk is less than 10 percent (calculated using a risk assessment tool), screening is not recommended.

The USPSTF reviewed new evidence regarding the reduction of risk for coronary heart disease (CHD) events in asymptomatic adults by screening with electrocardiography (EKG) compared with not screening and issued the following recommendations: The USPSTF recommends against screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at low risk for CHD events (D recommendation). (1) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events (I statement).

Risk Factors:

1. Hypercholesterolemia
2. Hypertension
3. Diabetes
4. Family history of CAD
   
5. Smoking history
6. Age
7. History of coronary Disease equivalent
   

Key Communication Concepts

• Provide Clear Recommendations: The majority of patients want information about their health, illness, and decision options.
  
  “The good news is I would not recommend any additional testing at this time as you are in great health.”
  
  "The American Academy of Family Physicians does not recommend routine screening with a stress test unless the patient is at high risk for heart disease."
  
  
• Elicit Patient Beliefs/Questions: Understanding patients’ treatment goals and perspectives about their health during the visit will help improve patient satisfaction and can shorten visits. Find out where the patient is coming from:
  
  "Do you have any questions for me about your health?" 
  
  "What are you worried about?"
  
  
• Provide Empathy, Partnership, Legitimation: Patients are more satisfied and more likely to adhere to recommendations if they feel understood, supported, and a sense of partnership with their physicians. Make it clear that you are on the patient's side (provide empathy and partnership):
  
  "I wish this test would help you, but it is unlikely to tell us what we want to know."
  
  "For someone like you who is already exercising, I look at other factors like your low cholesterol, the fact that you do not smoke, your normal blood pressure, weight and a family history with no heart disease. I see someone who is presently at low risk for heart disease and does not need a stress test. Stress tests can cause harm by causing us to do further unnecessary testing in low risk patient’s like you."
  
  
• Confirm Agreement/Overcome Barriers: Finding common ground and understanding patient perspective and barriers will help reach agreement and provide patient satisfaction and hopefully improve patient health outcomes.
  
  "I want be sure you are comfortable with this plan. I will see you at our next scheduled visit but feel free to call sooner if you have additional questions or concerns. Symptoms of heart disease you want to alert me about are chest pain with your exercise, any new shortness of breath."

References

1. Moyer VA, U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:512-518. Accessed November 21, 2012.
2. 2012 AAFP recommendations for preventive services guideline 
3. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary. J Am Coll Cardiol. 2010;56:2182-2199.
4. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29.