番茄社区

The U.S. Preventive Services Task Force (USPSTF) has not changed its stance against electrocardiography (ECG) for cardiovascular disease (CVD) screening in asymptomatic adults, with final recommendations echoing the draft document.

As they did in 2012, Susan Curry, PhD, of University of Iowa, Iowa City, and colleagues of the USPSTF recommended against ECG screening in asymptomatic adults at low risk of CVD events (risk below 10% over 10 years), noting potential for unnecessary subsequent invasive testing and other harms.

For asymptomatic individuals with intermediate or high risk, benefit from ECG was again deemed uncertain atop current risk assessment models like the Framingham Risk Score and Pooled Cohort Equations (I statement), according to the recommendations published online in the .

The document updates the on ECG screening for coronary heart disease. A draft version was released in late 2017 for public comment.

The basis for the recommendations was a meta-analysis of 16 studies (n=77,140) concluding:

• Screening with exercise ECG has no impact on cardiovascular composite outcomes in adults ages 50 to 75 years with diabetes (two randomized trials; n=1,151)
• Adding exercise ECG to traditional risk factors such as age, sex, current smoking, diabetes, total cholesterol level, and high-density lipoprotein cholesterol level produces small improvements in stratification (five cohort studies; n=9,582)
• Adding resting ECG to traditional risk factors produced small improvements in discrimination and appropriate risk classification for prediction of multiple cardiovascular outcomes, although evidence was limited by imprecision, quality, considerable heterogeneity, and inconsistent use of risk thresholds used for clinical decision making (nine cohort studies; n=66,407)

The extent of reclassification improvement ranged from 3.6% to 30% when ECG results were added to risk modeling with the Framingham Risk Score or Pooled Cohort Equations.

However, the group cautioned that the evidence reviewed still has many limitations, for example that no two studies evaluated the same model, risk category thresholds, and outcomes.

"In the context of present knowledge, the USPSTF report provides a cogent argument for excluding resting and exercise ECGs as part of the routine evaluation of asymptomatic, low-risk adult patients," agreed Robert Myerburg, MD, of University of Miami Miller School of Medicine, in a linked editorial.

"As pointed out by the USPSTF recommendations, the resting or the exercise ECG test is not useful, nor should it be touted, as a screening test for predicting outcomes in asymptomatic individuals without CVD," added Joseph Alpert, MD, of University of Arizona College of Medicine in Tucson, in a separate editorial in JAMA Cardiology.

However, Alpert said that his initial response to the new USPSTF recommendations was "that the task force has created a straw man that is easy to knock down. Indeed, the USPSTF has addressed, in my opinion, one rather minor aspect of ECG."

Legitimate uses for the ECG include the identification of inherited conditions associated with risk of either sudden cardiac arrest or heart failure, according to Myerburg. "An example emerges from Japan, where mandated medical evaluation of children before entering the first grade, and again before middle-school enrollment, includes screening ECGs. In a recent study, the prevalence of prolonged QT intervals in these children was greater than 1 per 1000 population, with many confirmed by genetic testing."

ECG screening can also be applied to competitive athletes and is already uniform among the major competitive professional team sports in the U.S., Myerburg said.

In any case, the use of screening ECGs leads to higher downstream cardiac testing use, more specialist consultations, and potentially higher rates of adverse events, including excess radiation exposure and procedural complications of angiography, commented R. Sacha Bhatia, MD, MBA, and Paul Dorian, MD, MSc, both of the University of Toronto, in a separate commentary published in JAMA Internal Medicine.

"Despite substantial evidence advising against screening ECG in asymptomatic patients of all risk groups, the practice still appears widespread. Nonindicated cardiac tests may be used in 12.8% of low-risk patients and 20.2% of high-risk patients, and in our prior study, 21.5% of low-risk patients received a screening ECG," Bhatia and Dorian wrote, emphasizing the need to research why unnecessary cardiac tests keep getting ordered and how to cut down on them.

The bottom line, according to them: "It is understandable that physicians want to do anything it takes to prevent a life-altering cardiovascular event in one of their patients, but in our rush to do something we need to be certain we are not inadvertently doing more harm than good."