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Level IV – Coronary Heart Disease with Electrocardiography Screening

Level IV Services: Preventive services that are not supported by evidence and should not be recommended.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events.”
  2. “The current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events.”
(USPSTF Last Revised 2012)
Grade of Recommendation:
  1. D
  2. I Statement

Level of Certainty:

  1. Moderate
  2. Insufficient
“Benefits:
For asymptomatic adults at low risk for CHD events, it is very unlikely that the information offered by resting or exercise ECG (beyond that obtained with conventional CHD risk factors) will result in a change in the patient's risk category (for example, from low to high risk) that would lead to a change in the patient's treatment and ultimately improve health outcomes. Serious possible harms are associated with resting or exercise ECG screening. The most important harm is exposure to potential adverse effects of invasive tests. Therefore, the USPSTF concluded with moderate certainty that screening ECG provides no net benefit for asymptomatic, low-risk patients.
For asymptomatic adults at intermediate or high risk for CHD events, there is no evidence to determine the extent to which resting or exercise ECG adds to the usual ascertainment of conventional CHD risk factors (that is, Framingham risk factors) and that it results in a change in risk management and ultimately reduces CHD-related events. As with low-risk adults, serious possible harms are associated with resting or exercise ECG in asymptomatic adults at intermediate or high risk, and thus the USPSTF could not assess the net benefit of ECG screening.
Harms:
Adverse events directly associated with resting ECG are extremely rare and largely related to cutaneous allergic reactions to ECG pads and adhesives or anxiety about test outcome. The USPSTF is not aware of any recent studies that report harms directly associated with resting ECG screening. In low-risk asymptomatic populations, most positive ECG results occur in persons who will not have a CHD event in the next 5 to 10 years. One study reported that 71% of asymptomatic adults with abnormal exercise treadmill ECG results had no angiographically demonstrable coronary artery stenosis. Adverse events associated with exercise ECG may include the triggering of a cardiovascular event, musculoskeletal injury and anxiety about test outcome. The overall risk for a serious adverse event (one that requires hospitalization or causes sudden death) is estimated to be 1 in 10,000 tests.
Harms are associated with follow-up testing or interventions that follow resting or exercise ECG screening. Older studies, mostly from the 1980s and 1990s, report rates of 0.6 to 2.9% for angiography in asymptomatic adults after an abnormal exercise ECG result. Two studies report rates of 0.1% and 0.5% for subsequent revascularization. On the basis of large, population-based registries that include symptomatic persons, the risk for any serious adverse event from angiography is about 1.7%, including risk for death (0.1%), MI (0.05%), stroke (0.07%) or arrhythmia (0.4%). The USPSTF did not find any recent studies that directly address the potential harms of anxiety or labeling.
Benefits-Harms Assessment:
There is substantial and consistent evidence that identifying and treating traditional, modifiable CHD risk factors – such as hypertension, abnormal lipid levels, diabetes, smoking, physical inactivity and diet – improve cardiovascular outcomes. These risk factors are linked to the biological understanding of the pathophysiology of CHD. Electrocardiography measures the electrical activity in the heart and results can be abnormal for many reasons, only some of which are because of CHD. In low-risk patients, these abnormalities are unlikely to result from CHD; in intermediate- and high-risk patients, they are more likely to result from CHD but there is no evidence that targeting these abnormalities instead of or in addition to modifiable risk factors has benefit or biological plausibility.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsacad.htm
Implementation Tools and Resources:
Screening for Coronary Heart Disease with Electrocardiography