New Guidelines Say No to Screening EKGs for Low-Risk Patients
Recommendations mirror those issued in 2004 because science hasn't changed, experts say
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Monday, July 30, 2012
The U.S. Preventive Services Task Force also determined there is not enough evidence to recommend for or against screening people without symptoms who are at moderate or high risk of heart disease.
The task force published its recommendations online July 31 in the Annals of Internal Medicine. They echo the task force's previous guidelines on EKG screening, which came out in 2004.
"The systematic review didn't come up with any science that would change the 2004 recommendation -- it is in fact the same as in 2004," task force co-vice chair Dr. Michael LeFevre said, explaining that the task force makes a general policy of updating all its recommendations about every five years.
"When you have an asymptomatic low-risk population, the chance that you're going to do harm instead of good [by screening] goes way up," LeFevre said.
In a low-risk population, abnormalities that show up in an EKG are probably not due to actual heart disease and are probably false positives instead, LeFevre explained. "Inevitably, that leads to further testing, including invasive testing such as heart catheterization" that carries the risk of rare complications like heart rhythm disturbances, he added.
Although the task force did not come to a conclusion about moderate- and high-risk groups of people based on the current evidence, "as a practicing family physician, it would be unusual for me to do an EKG in any asymptomatic person," LeFevre said.
The task force stated that evaluating traditional risk factors including bad cholesterol, high blood pressure and smoking were important, and that it was not clear that EKGs added any information to this assessment.
"If someone is high risk, I am going to treat risk factors regardless of what the EKG shows," LeFevre said.
On the other hand, EKGs are clearly helpful for understanding why a patient is having heart disease symptoms -- the most common being chest pain and heart flutters, or when the heart skips a beat, LeFevre said. "That becomes a diagnostic rather than a screening test," and the task force recommendations do not cover the merit of EKGs as a diagnostic tool, he noted.
Heart disease, also known as coronary heart disease or coronary artery disease, is the leading cause of death in the United States. More than 1 million people in the United States experience fatal or nonfatal heart attacks, or die of sudden cardiac arrests yearly, accounting for a third of all deaths in people over the age of 35, according to the task force.
An EKG test measures the strength and rhythm of the heartbeat via a series of electrodes placed across the body. The current recommendations apply to EKGs that are done on patients while they're lying down, or resting EKGs, as well as exercise EKGs, or stress tests.
To update the recommendations, the task force reviewed both new and old studies, LeFevre said.
Most doctors would probably agree with the recommendations, especially in low-risk patients, said Dr. Robert Myerburg, a cardiologist at the University of Miami Miller School of Medicine.
"My feeling from the kinds of referrals that I see is that physicians are doing less of the routine screening than they used to," he added.
However, Myerburg thinks that people over 35 should still have a baseline EKG because it could make it easier to pick out problems in later diagnostic EKGs. The task force recommends against baseline EKGs, stating that there is not enough evidence for their usefulness.
"It's hard not to agree with their conclusion" about the absence of benefit in screening low-risk, asymptomatic individuals, Myerburg said. However, the risks associated with EKG and the tests it leads to may be overstated, he pointed out.
"I want physicians to have the flexibility to exert their own judgment for individual patients," Myerburg said.
For example, Myerburg would consider "superseding the general recommendations" in the case of patients with family members who had sudden cardiac deaths without any warning signs of heart disease, because they could be at risk of the same fate.
Insurance companies generally cover EKGs and will hopefully continue to do so if physicians order them, Myerburg said.
"The test costs between $35 and $100 in the middle of Missouri," LeFevre said.
"If patients are worried about heart disease, the major effort should be in the detection and management of risk factors rather than worrying about screening with EKG," LeFevre said.
The American Heart Association and the American College of Cardiology recommend that a family history of heart disease be taken for every patient and that EKG screening is "reasonable" in asymptomatic people with hypertension or diabetes.
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