Dac Screening

Putting Prevention into Practice
An Evidence-Based Approach
Screening for Cardiovascular Disease

Risk with Electrocardiography
Howard Tracer, MD, U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality
Yuri T. Jadotte, MD, MPH, PhD, Clinical Assistant Instructor and Preventive Medicine Resident,
Stony Brook University School of Medicine
Case Study
A 55-year-old man presents for an annual visit. He has no history of hypertension, cardiovascular
disease (CVD), or diabetes mellitus;has never smoked;and has no family history of CVD. His lipid
panel results from one year ago were normal, and he has no current symptoms of CVD. According
to the Pooled Cohort Equations from the American College of Cardiology/American Heart Asso-
ciation, this patient has a low 10-year risk of a CVD event. He has never been screened with elec-
trocardiography (ECG) to identify early evidence of CVD and asks whether he should be screened.
Case Study Questions 2. Which of the following statements regarding

1. Based on the U.S. Preventive Services Task CVD risk factors, risk stratification, and screen-
Force (USPSTF) recommendation on screening ing with ECG are correct?
for CVD risk with ECG, which one of the fol- l A. No significant harms are associated
lowing statements about screening is accurate with screening for CVD risk with resting
regarding counseling this patient? or exercise ECG.
l A. He should be screened because male l B. Screening for CVD risk with resting or
sex is a risk factor for CVD. exercise ECG does not help with risk
l B. He should be screened because older stratification of patients to inform treat-
age is a risk factor for CVD. ment decisions.
l C. He should be considered for screening l C. Accurate identification of persons at
after a discussion of the benefits and high risk of CVD events provides the
harms. opportunity for more intensive risk-
l D. He should not be screened because he factor management to reduce the
has no family history of CVD. likelihood of such an event.
l E. He should not be screened because l D. Screening for CVD risk with exercise
the evidence suggests there is no net ECG leads to improvements in health
benefit of screening in asymptomatic, outcomes, particularly for higher risk
low-risk patients. populations with diabetes.
See related U.S. Preventive Services Task Force Recommendation Statement at https://w ww.aafp.org/afp/2018/0915/od1.html.
This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation
Statement and supporting documents on the USPSTF website (https://w ww.uspreventiveservicestaskforce.org). The practice
recommendations in this activity are available at https://w ww.uspreventiveservicestaskforce.org/Page/Document/Update
SummaryFinal/cardiovascular-disease-risk-screening-with-electrocardiography.
This series is coordinated by Kenny Lin, MD, Deputy Editor.
A collection of Putting Prevention into Practice published in AFP is available at https://w ww.aafp.org/afp/ppip.
CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz on page 345.
Author disclosure: No relevant financial affiliations.
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PUTTING PREVENTION INTO PRACTICE
3. Which one of the following recommendations does the 2. The correct answers are B and C. The USPSTF found
USPSTF advise for patients with an intermediate or high adequate evidence that screening with resting or exer-
10-year risk of a CVD event? cise ECG in asymptomatic adults leads to harms that are
l A. Patients should be screened because the bene- at least small and possibly moderate, including unneces-
fits of screening in this population outweigh the sary invasive procedures, overtreatment, and labeling.1 The
harms. information obtained from screening for CVD with ECG
l B. Patients should be screened after careful consid- (beyond that obtained from conventional CVD risk factors)
eration of the benefits and harms. has not been found to help with the risk stratification of
l C. Patients should be screened if they also have patients to inform treatment decisions.1 Accurate identifi-
diabetes or uncontrolled hypertension. cation of persons at high risk of CVD events provides the
l D. There is insufficient evidence on the balance of opportunity for more intensive risk-factor management
benefits and harms of screening for CVD risk with (e.g., controlling hypertension or abnormal cholesterol lev-
ECG in this population. els) to reduce the likelihood of such an event. In addition,
l E. Patients should not be screened because there is identifying persons at low risk may allow for a reduction
adequate evidence that the harms of screening in interventions among patients not likely to benefit from
are equal to or outweigh the benefits. them.1 Randomized controlled trials of screening with exer-
cise ECG found no improvement in health outcomes, even
among higher risk populations with diabetes.2
Answers 3. The correct answer is D. Based on the results of a sys-
1. The correct answer is E. For asymptomatic adults at low tematic evidence review, the USPSTF concluded that the
risk of CVD events, it is highly unlikely that the information current evidence is insufficient to assess the balance of ben-
from resting or exercise ECG (beyond that obtained with efits and harms of screening with resting or exercise ECG to
conventional CVD risk factors) will change the patient’s prevent CVD events in asymptomatic adults at intermediate
risk category or lead to a change in treatment and ultimately or high risk of CVD events.1
improve health outcomes. Male sex and older age (as well as The views expressed in this work are those of the authors and
hypertension, current smoking, abnormal lipid levels, dia- do not reflect the official policy or position of the Uniformed
betes, obesity, and physical inactivity) are associated with Services University of the Health Sciences, the Department of
an increased risk of CVD events, and many of these risk Defense, or the U.S. government.
factors are combined to estimate a person’s 10-year risk of a References
CVD event by using various calculators and models (such as
1. US Preventive Services Task Force. Screening for cardiovascular disease
the Framingham Risk Score and the Pooled Cohort Equa- risk with electrocardiography:US Preventive Services Task Force rec-
tions).1 However, given the patient’s low 10-year risk of CVD, ommendation statement. JAMA. 2018;319(22):2308-2314.
screening with ECG is not recommended. The evidence 2. Jonas DE, Reddy S, Middleton JC, et al. Screening for cardiovascular
suggests that the harms of screening for CVD risk with ECG disease risk with resting or exercise electrocardiography:evidence
report and systematic review for the US Preventive Services Task Force.
are equal to or outweigh the benefits in asymptomatic adults JAMA. 2018;319(22):2315-2328. ■
at low risk of CVD events. Thus, the USPSTF recommends
against screening with resting or exercise ECG to prevent
CVD events in this patient population.1
376 American Family Physician www.aafp.org/afp Volume 98, Number 6 ◆ September 15, 2018

Dac Screening

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Putting Prevention into Practice

Screening for Cardiovascular Disease

Case Study Questions 2. Which of the following statements regarding

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