June 14, 2018

Stop giving ECGs to low-risk, asymptomatic patients USPSTF says

Daily Briefing

    The U.S. Preventive Services Task Force (USPSTF) on Tuesday published recommendations in JAMA that reiterates previous guidance against performing electrocardiography (ECG) screening on asymptomatic patients at low risk for cardiovascular diseases.

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    Why a doctor would perform an ECG

    An ECG measures the heart's electrical activity and can be used to identify irregular heart rhythms.

    For years, the USPSTF and several medical groups have recommended against using ECG in patients who are at low risk for cardiovascular diseases and have no cardiovascular disease symptoms.  

    Nonetheless, data from the National Center for Health Statistics suggest ECGs are performed in about 4% of routine exams.

    USPSTF's recommendation

    USPSTF based its latest recommendations on a meta-analysis of 16 studies. According to USPSTF, "the current evidence review did not include association studies but addressed whether the addition of screening with resting or exercise ECG improves health outcomes compared with traditional CVD risk assessment in asymptomatic adults.

    The recommendation reiterates its 2012 stance on the topic, stating that asymptomatic patients whose 10-year risk for cardiovascular disease event is under 10% should not receive an ECG. The panel noted ECGs can lead to unnecessary, potentially dangerous follow-up testing.

    As such, USPSTF gave ECG screening in low-risk asymptomatic adults a "D" rating, which according to the panel means "[t]here is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."

    In addition, USPSTF in the recommendation upheld its "I statement" regarding ECG in asymptomatic individuals with intermediate or high cardiovascular disease risk. An "I statement," USPSTF explained, means the panel "concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined."

    The researchers said that the benefit of ECG versus the risk was uncertain when compared with current risk assessment models, such as the Framingham Risk Score and Pooled Cohort Equations.  


    Seth Landefeld, who chairs the medicine department at the University of Alabama at Birmingham and was on the committee that issued the new recommendations, said, "There is no evidence of benefits of doing ECG screening that would outweigh the possible harms." For instance, he said some follow-up tests, such as angiograms, can inadvertently damage the heart in rare cases.

    Robert Hendel, chief of cardiology at Tulane University who spoke on behalf of the American College of Cardiology, said that the recommendations are "very reasonable," adding that, "if there's really no benefit and it may open a can of worms, then why are we doing it?"

    In an accompanying editorial, Robert Myerburg, a professor of medicine at the University of Miami Miller School of Medicine, said ECGs can be helpful in identifying inherited conditions associated with an individual's risk of heart attack or heart failure, as well as for competitive athletes. However, he said "conventional risk factors have become so strong and so useful in preventing heart disease that the value of doing a routine ECG as part of an annual physical has faded" (Stein, "Shots," NPR, 6/12; Lou, MedPage Today, 6/12; USPSTF, JAMA, 6/12).

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