This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for coronary heart disease and the supporting scientific evidence, and updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, Second Edition: Periodic Updates.1
Summary of Recommendations
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CHD is the leading cause of death in the United States; more than 700,000 of the deaths in 2000 were due to heart disease.4 The overall costs of CHD and stroke in 2003 are estimated to be greater than $350 billion.5
Many clinicians ascertain a person's overall risk for CHD events by screening for cardiac risk factors and incorporating that information into risk prediction equations derived from the Framingham or other cohort studies.3,6 Asymptomatic adults clearly benefit from risk factor modification proportional to their degree of CHD risk (i.e., more intensive risk factor modification for people at higher risk).7 Since those at high risk for CHD may already be receiving interventions to maximally reduce their risk for CHD events, screening may potentially be of greatest benefit to those presumed to be at intermediate risk for CHD who could be reclassified as being at high risk (and thus treated more aggressively) after additional testing. In addition to risk factor reduction, persons with symptoms of CHD who have severe CAS (defined as either triple vessel or left main coronary artery atherosclerotic disease with poor left ventricular function) clearly benefit from CABG or percutaneous transluminal coronary angioplasty (PTCA).8-10 Among the asymptomatic population, those at higher risk for CHD events have a higher prevalence of severe CAS; thus, the yield of screening is expected to be greater in this population. However, it is uncertain whether this increased yield increases the detection of people with severe CAS to an important degree, and whether invasive revascularization procedures would benefit those who are asymptomatic as much as those who have symptoms of CAS.
The USPSTF reviewed the evidence as to whether supplementing the conventional CHD risk ascertainment strategy with additional screening using ECG, ETT, or EBCT, or using these 3 tests to identify people with severe CAS earlier, would lead to improved health outcomes in asymptomatic persons. The USPSTF found no randomized controlled trials (RCTs) with health outcomes that examined the extent to which ECG, ETT, or EBCT scanning for coronary calcium provided additional prognostic information beyond the currently used risk factor calculations. The Task Force further found that the 3 screening tests—ECG, ETT and EBCT—have poor to fair accuracy in predicting CHD events.
Systematic reviews have reported that the sensitivity of resting ECG abnormalities for CHD events is low.3,11 The prevalence of the most common ECG abnormalities (Q waves, left ventricular hypertrophy, bundle-branch blocks, and ST-segment depression) ranges from 1 percent to 10 percent.3 Only a few studies have examined ECG abnormalities in the black population. Although major ECG abnormalities may be more prevalent in black men than in white men, these abnormalities may not confer the same risk for CHD death in black men (relative risk [RR], 1.95; 95 percent confidence interval [CI], 0.93-4.11) as in white men (RR, 2.72; 95 percent CI, 1.47-5.04).12
The sensitivity of ETT for the prediction of CHD events 3 to 12 years in the future ranges from 40 percent to 62 percent; the positive predictive value (PPV) ranges from 6 percent to 48 percent. The higher sensitivity of ETT reported in older studies may not be accurate because of the possibility of spectrum bias.13,14 The prevalence of an abnormal ETT (ST-segment depression of > 1 mm) reportedly ranges from 5 percent to 25 percent.3 The yield of ETT in detecting severe CAS in asymptomatic middle-aged men is estimated to be 0.5 percent.3,15 The PPV for future CHD in recent cohort studies (most of them conducted with asymptomatic men) is low (range, 6 percent-48 percent).3 Adding nuclear perfusion to ECG analysis may increase sensitivity somewhat; however, the low PPV of ETT is due mainly to the low prevalence of CHD in asymptomatic persons and cannot be corrected simply by improving test accuracy.
For patients with symptoms of CHD, EBCT has a sensitivity of 80 percent and a specificity of 40 percent for detecting angiographically demonstrated CAS;16 similar data for those who have no symptoms are lacking. A systematic review reported that higher calcium scores on EBCT were associated with higher risk for CHD events.3 This review concluded that EBCT may have a role in better defining risk for CHD events in those who have been identified as being at intermediate risk based on traditional risk factors, but no study has examined the effect of EBCT data on clinical decision-making.3
Potential harms of screening asymptomatic patients for CHD include unnecessary invasive testing (e.g., coronary angiography) and "labeling" of those who have had false-positive test results. In low-risk asymptomatic populations, most positive ECG test results occur in those who will not have a CHD event in the next 5 to 10 years.3 One study reported that 71 percent of those without symptoms who had an abnormal ETT had no angiographically demonstrable CAS.17 While the yield of screening is low in those at low risk for CHD, the potential for harm from false-positive tests is high. The USPSTF judged that the benefits of screening people at low risk for CHD would not outweigh the potential harms.
Due to the limited sensitivity of resting ECG and the low prevalence of CHD in asymptomatic adults, a majority of CHD events will occur among those with an initially normal ECG (i.e., those who test false negative).18 ETT can be normal or non-diagnostic in a large proportion of patients who will go on to have a CHD event, which may be explained partly by the fact that many acute CHD events result from sudden occlusion of a previously unobstructed artery segment.19
A large study, the Multi-Ethnic Study of Atherosclerosis (MESA), is ongoing. Data from this study will help to examine the independent prognostic information derived from EBCT in the context of accurate measurement of traditional risk factors and extended follow-up.20 In the absence of such data for ECG, ETT, or EBCT, the USPSTF concluded there is insufficient evidence to recommend for or against screening for CHD.
The American College of Cardiology/American Heart Association (ACC/AHA) gave a class III recommendation for screening with exercise testing in asymptomatic persons without known coronary artery disease (CAD). For the evaluation of those with multiple risk factors as a guide to risk-reduction therapy, and for the evaluation of asymptomatic men older than 45 and women older than 55 who (a) plan to start vigorous exercise, (b) are involved in occupations in which impairment might impact public safety, or (c) are at high risk for CAD due to other diseases, the ACC/AHA gave screening with exercise testing a class IIb recommendation. For the evaluation of asymptomatic persons with diabetes who plan to start vigorous exercise, the ACC/AHA gave screening with exercise testing a class IIa recommendation.21 The ACC/AHA Writing Group does not recommend EBCT to diagnose obstructive CAD.16 The American Academy of Family Physicians does not recommend use of routine ECG as part of a periodic health or a pre-participation physical exam in either asymptomatic children or adults.22
1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion, 1996:3-14.
2. Pignone M. Screening for asymptomatic coronary artery disease using exercise treadmill testing: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004.
3. Pignone M, Fowler-Brown A, Pletcher M, Tice JA. Screening for Asymptomatic Coronary Artery Disease. Systematic Evidence Review No. 22 (Prepared by the Research Triangle Institute—University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality. February 2003. (Available on the AHRQ Web site at: www.ahrq.gov/clinic/serfiles.htm.)
4. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Fast Stats A to Z: Leading Causes of Death. Available at: http://www.cdc.gov/nchs/fastats/lcod.htm. Accessed April 4, 2003.
5. American Heart Association. Cardiovascular Disease Cost. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4475. Accessed November 25, 2003.
6. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97(18):1837-47.
7. 27th Bethesda Conference. Matching the Intensity of Risk Factor Management with the Hazard for Coronary Disease Events. September 14-15, 1995. J Am Coll Cardiol 1996;27(5):957-1047.
8. Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation 1983;68(5):939-50.
9. Parisi AF, Folland ED, Hartigan P. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators. N Engl J Med 1992;326(1):10-6.
10. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Intervention Treatment of Angina (RITA) trial. Lancet 1993;341(8845):573-80.
11. Ashley EA, Raxwal V, Froelicher V. An evidence-based review of the resting electrocardiogram as a screening technique for heart disease. Prog Cardiovasc Dis 2001;44(1):55-67.
12. Kannel WB, Anderson K, McGee DL, Degatano LS, Stampfer MJ. Nonspecific electrocardiographic abnormality as a predictor of coronary heart disease: the Framingham Study. Am Heart J 1987;113(2 Pt 1):370-6.
13. Ashley EA, Myers J, Froelicher V. Exercise testing in clinical medicine. Lancet 2000;356(9241):1592-7.
14. Froelicher VF, Callaham PR, Angelo J, Lehmann KG. Treadmill exercise testing and silent myocardial ischemia. Isr J Med Sci 1989;25(9):495-502.
15. Blair SN 3rd, Kohl HW, Barlow CE, Paffenbarger RS Jr, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA 1995;273(14):1093-8.
16. O'Rourke RA, Brundage BH, Froelicher VF, et al. American College of Cardiology/American Heart Association Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation 2000;102(1):126-40.
17. Hopkirk JA, Leader S, Uhl GS, Hickman JR Jr, Fischer J. Limitation of exercise-induced R wave amplitude changes in detecting coronary artery disease in asymptomatic men. J Am Coll Cardiol 1984;3(3):821-6.
18. Sox HC Jr, Garber AM, Littenberg B. The resting electrocardiogram as a screening test. A clinical analysis. Ann Intern Med 1989;111(6):489-502.
19. Coplan NL, Fuster V. Limitations of the exercise test as a screen for acute cardiac events in asymptomatic patients. Am Heart J 1990;119(4):987-90.
20. Bild DE, Bluemke DA, Burke GL, et al. Multi-ethnic study of atherosclerosis: objectives and design. Am J Epidemiol 2002;156:871-81.
21. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002;106(14):1883-92.
22. American Academy of Family Physicians. Clinical care and Research. Leawood, Kansas. Available at: http://www.aafp.org/x10593.xml. Accessed November 20, 2003.
Members of the U.S. Preventive Services Task Force* are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, MD); Ned Calonge, M.D., M.P.H. (Acting Chief Medical Officer, Colorado Department of Public Health and Environment, Denver, CO); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Joxel Garcia, M.D., M.B.A. (Deputy Director, Pan American Health Organization, Washington, DC); Russell P. Harris, M.D., M.P.H. (Associate Professor of Medicine, Sheps Center for Health Services Research, University of North Carolina School of Medicine, Chapel Hill, NC); Mark S. Johnson, M.D., M.P.H. (Professor of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Carol Loveland-Cherry, Ph.D., R.N. (Executive Associate Dean, School of Nursing, University of Michigan, Ann Arbor, MI); Virginia A. Moyer, M.D., M.P.H. (Professor, Department of Pediatrics, University of Texas at Houston, Houston, TX); C. Tracy Orleans, Ph.D. (Senior Scientist, The Robert Wood Johnson Foundation, Princeton, NJ); Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc, West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine and Director of Research, Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).
*Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to www.ahrq.gov/clinic/uspstfab.htm.
Address correspondence to: Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force; c/o Program Director, USPSTF; 540 Gaither Road; Rockville, MD 20850; E-mail: uspstf@ahrq.gov.
The complete information on which this statement is based, including evidence tables and references, is available in the summary article2 and the systematic evidence review3 on this topic, available through the USPSTF Web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse™ (www.guideline.gov). The summary article and the recommendation statement are also available from the Agency for Healthcare Research and Quality (AHRQ) Publications Clearinghouse in print through subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. To order, contact the clearinghouse at 1-800-358-9295 or E-mail ahrqpubs@ahrq.gov.
The summary article and the recommendation statement are also available in print by subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. Select for order form: PDF Version (230 KB), Text Version. The cost of a subscription is $60 and can be ordered through the AHRQ Publications Clearinghouse (call 1-800-358-9295 or E-mail ahrqpubs@ahrq.gov).
Source: U.S. Preventive Services Task Force. Screening for Coronary Heart Disease: Recommendation Statement. Ann Intern Med 2004;240.
Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
Current as of February 2004
Internet Citation:
U.S. Preventive Services Task Force. Screening for Coronary Heart Disease: Recommendation Statement. February 2004. Originally in Ann Intern Med 2004;240. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/chd/chdrs.htm
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