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Screening Asymptomatic Adults for Coronary Heart Disease With Resting or Exercise Electrocardiography

Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation

Evidence Syntheses, No. 88

Investigators: , MD, , MD, , MLS, , PhD, , MA, and , MD, FACP.

Oregon Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 11-05158-EF-1

Structured Abstract

Background:

Coronary heart disease is the leading cause of death in the United States in adults. Traditional risk factors do not account for all of the excess risk associated with coronary heart disease. Screening for abnormalities with resting or exercise electrocardiography (ECG) could help identify persons at higher risk for coronary heart disease who might benefit from interventions to reduce cardiovascular risk.

Purpose:

To update the 2004 U.S. Preventive Services Task Force (USPSTF) evidence review on screening for resting or exercise ECG abnormalities in asymptomatic adults.

Data Sources:

We searched Ovid MEDLINE from January 2002 through January 2011 and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials through the fourth quarter of 2010. We supplemented electronic searches with reviews of reference lists, including prior USPSTF reviews.

Study Selection:

We included randomized controlled trials and prospective cohort studies that evaluated benefits or harms of screening compared with no screening in asymptomatic adults, or evaluated use of interventions to reduce cardiovascular risk (lipid-lowering therapy and aspirin) in screened persons compared with unscreened persons. We included prospective cohort studies that evaluated the usefulness of screening for abnormalities with resting or exercise ECG for predicting subsequent cardiovascular events, after controlling for at least five of the seven Framingham risk factors.

Data Extraction:

Data were abstracted by two investigators and discrepancies were resolved by consensus. Quality was assessed based on methods developed by the USPSTF.

Data Synthesis (Results):

No study evaluated benefits of screening compared with no screening, or use of lipid-lowering therapy or aspirin following screening. No study estimated effects of screening on reclassification. Two studies found that resting or exercise ECG findings plus traditional risk factor assessment resulted in a slight increase in the C statistic compared with traditional risk factor assessment alone.

Twenty-seven prospective cohort studies (10 rated good quality) with over 170,000 subjects evaluated resting ECG abnormalities and 38 prospective cohort studies (19 rated good quality) with over 90,000 subjects evaluated exercise ECG abnormalities as predictors of subsequent cardiovascular events, after adjusting for traditional risk factors. Pooled analyses showed that abnormalities on resting (ST segment abnormalities, T wave abnormalities, ST segment or T wave abnormalities, left ventricular hypertrophy, bundle branch block, left axis deviation) or exercise (ST segment depression with exercise, failure to reach maximum target heart rate, low exercise capacity or fitness) ECG were associated with increased risk of subsequent cardiovascular events, after adjusting for traditional risk factors (pooled hazard ratio estimates from 1.4 to 2.1).

Evidence on direct harms associated with screening with resting or exercise ECG is very limited, but direct harms appear minimal (resting ECG) or small (exercise ECG). No study estimated risks of downstream harms associated with subsequent testing or interventions, though rates of angiography after exercise ECG ranged from 0.6 to 2.9 percent.

Limitations:

We only included English-language studies. Statistical heterogeneity was present in several of the pooled analyses.

Conclusions:

Abnormalities on resting or exercise ECG are associated with an increased risk of subsequent cardiovascular events after adjusting for traditional risk factors, but the clinical implications of these findings are unclear.

Contents

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

3181 SW Sam Jackson Park Road, Portland, OR 97239; www​.ohsu.edu/epc

Acknowledgements: The authors acknowledge AHRQ Medical Officer Tracy Wolff, MD, MPH, and USPSTF members Susan Curry, PhD, Michael LeFevre, MD, MSPH, Joy Melnikow, MD, MPH, and Sanford Schwartz, MD, for their contributions to this report.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. HHSA-290-2007-10057-I-EPC3, Prepared by: Oregon Evidence-based Practice Center, Oregon Health & Science University2,

Suggested citation:

Chou R, Arora B, Dana T, Fu R, Walker M, Humphrey L. Screening Asymptomatic Adults for Coronary Heart Disease With Resting or Exercise Electrocardiography: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 88. AHRQ Publication No. 11-05158-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; September 2011.

This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0024). The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

2

3181 SW Sam Jackson Park Road, Portland, OR 97239; www​.ohsu.edu/epc

Bookshelf ID: NBK63671PMID: 21977523
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