Is cardiac stress testing appropriate in asymptomatic adults at low risk?
A 48-year-old insurance executive is offered the option of several health insurance packages at the time of a promotion. He is healthy and a non-smoker; both his parents are alive and well; and he takes only vitamins and fish oil supplements on a regular basis. His levels of total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol are all in the normal range, as is his blood pressure. He plans to purchase the lowest price policy, but wants to know if he should also get a stress test to best guide his care.
GUIDELINES RECOMMEND AGAINST TESTING
Patients who are at low risk of disease and without symptoms should not undergo cardiac stress testing. The test is unlikely to be helpful in these patients and may expose them to harm unnecessarily. Cardiac stress testing such as exercise electrocardiography is most useful in patients who have chest pain and shortness of breath on exertion, to look for underlying cardiovascular disease. Despite this, the test is often used inappropriately as part of a routine health evaluation in low-risk, asymptomatic people, such as this patient.
Recent high-quality guidelines address exercise electrocardiography as a screening test for cardiovascular disease in asymptomatic, low-risk adults.
The US Preventive Services Task Force 2012 guideline1 recommends against screening with exercise electrocardiography for predicting coronary heart disease events in adults with no symptoms and at low risk of these events. A systematic review found no data from randomized controlled trials or prospective cohort studies of this test to screen asymptomatic adults compared with no screening.2
The American Academy of Family Physicians (AAFP) 2012 guideline3 recommends against routine screening with exercise electrocardiography either for the presence of severe coronary artery stenosis or for predicting coronary events in adults at low risk. The AAFP guideline notes that there is moderate or high certainty of no net benefit or that the harms outweigh the benefits of exercise electrocardiography in adults at low risk and without symptoms.
The 2010 joint guideline of the American College of Cardiology and the American Heart Association4 does not comment on the role of screening exercise electrocardiography in low-risk asymptomatic adults, but states that a physician may consider ordering exercise electrocardiography in asymptomatic adults at intermediate risk of coronary heart disease. The guideline recommends that the individual physician decide whether screening exercise electrocardiography is warranted in a patient at intermediate risk.
The Choosing Wisely initiative
As part of the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, a number of medical specialty societies have published lists of recommendations and issues that physicians and patients should question and discuss. Cardiac stress testing in low-risk asymptomatic patients is on the list of a number of organizations, including the American College of Physicians, the American College of Cardiology, the AAFP, and the American Society of Nuclear Cardiology. These lists can be found at www.choosingwisely.org.
