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USPSTF Recommends Against Screening for CHD

The third U.S. Preventive Services Task Force (USPSTF) has been releasing new and updated guidelines during the past 3 years (guidelines homepage; Journal Watch May 15 2001; and Journal Watch Mar 26 2004).

USPSTF 3 concludes each of its guidelines with a recommendation, graded as follows:

A -- The intervention is strongly recommended.

B -- The intervention is recommended.

C -- The USPSTF makes no recommendation for or against the intervention.

D -- The intervention is not routinely recommended.

I -- Evidence is insufficient to recommend for or against the intervention.

The USPSTF has updated its systematic review of the literature on screening for coronary heart disease (CHD). Given the lack of evidence that testing can detect cases of CHD in adults who are at low risk or that testing can improve health outcomes, the USPSTF recommends against routine screening with resting electrocardiography (ECG), exercise treadmill testing (ETT), or electron-beam computerized tomography (EBCT). Recommendation: D

ECG and ETT both are relatively insensitive for detecting CHD. In no studies has EBCT been compared with angiography in asymptomatic adults. None of the tests (ECG, ETT, or EBCT) is very accurate for predicting CHD events. No randomized trials have been conducted to evaluate the effect on health outcomes of screening with these tests.

Testing can detect a small number of cases of CHD that otherwise would not be identified (by symptoms) in people who do not have conventional risk factors. But false-positive test results can lead to harm in the form of unnecessary invasive procedures, overtreatment, and labeling. Conversely, false-negative results can lead to false reassurance. The task force did note that patients' occupations, such as those in which a sudden catastrophic event could harm others (e.g., pilots), could influence screening decisions.

The task force found insufficient evidence to recommend for or against screening in adults at higher risk for CHD. This recommendation was based on the same type of evidence and rationale as that for people at lower risk, but the task force could not determine the balance of benefits and harms. Recommendation: I

Comment: With so much general press coverage given to tests such as EBCT, it is easy to forget that these tests might not lead to better health outcomes. Obviously, CHD should be recognized and treated sooner rather than later. But appropriately, the USPSTF has held screening and intervention for CHD to the same evidence standards as screening and intervention for other conditions. At the time of publication, the full text of the recommendation statement and the systematic review was available free of charge.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine April 13, 2004

Citation(s):

U.S. Preventive Services Task Force. Screening for coronary heart disease: Recommendation statement. Ann Intern Med 2004 Apr 6; 140:569-72.

• Original article (Subscription may be required)
• Medline abstract (Free)

Fowler-Brown A et al. Exercise tolerance testing to screen for coronary heart disease: A systematic review for the technical support for the U.S. Preventive Services Task Force. Ann Intern Med 2004 Apr 6; 140:W9-W24. (http://www.annals.org/cgi/content/full/140/7/W-9)