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Chou R, Arora B, Dana T, et al. 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 [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Sep. (Evidence Syntheses, No. 88.)


Scope and Purpose

Coronary heart disease (CHD) is the leading cause of death in the United States in both men and women, accounting for nearly 40 percent of all deaths each year.1,2 Each year, more than 1 million Americans experience nonfatal or fatal myocardial infarction (MI) or sudden death from CHD. Although angina is a common presenting symptom of CHD, in some persons the first manifestation of CHD is MI, sudden death, or another serious cardiovascular event. (See Appendix A for a list of all abbreviations included in this report.)

The risk for incident CHD in asymptomatic persons can be predicted based on the “traditional” risk factors included in the Framingham risk score (age, sex, blood pressure, serum total cholesterol level, low-density lipoprotein [LDL] or high-density lipoprotein [HDL] cholesterol level, cigarette smoking, and diabetes). However, these factors do not explain all of the excess risk.3,4 Consequently, there has been a long-standing interest in supplementing traditional risk factor assessment with other methods of screening for CHD, including resting or exercise electrocardiography (ECG). Abnormal findings on ECG might identify those at higher risk of CHD events who would not be identified based on traditional risk factors alone.5 For example, based on the Framingham risk scoring system, persons at intermediate risk are typically defined as having a 10 to 20 percent risk for CHD death or nonfatal MI over 10 years. Abnormal findings on resting or exercise ECG could reclassify some of these persons as low risk (10-year risk <10 percent) and others as high risk (10-year risk >20 percent). Such reclassification, if accurate, could guide use of more aggressive cardiovascular risk reduction therapies in persons reclassified as high risk, which might reduce future CHD events.6 However, direct evidence showing benefits associated with implementation of such strategies is lacking, and the classification thresholds remain somewhat arbitrary.

The U.S. Preventive Services Task Force (USPSTF) last reviewed the evidence on screening for CHD with resting or exercise ECG in 2004.7,8 The USPSTF commissioned an update of the evidence review in 2009 in order to revisit its recommendation on screening with resting or exercise ECG. The purpose of this report is to systematically evaluate the current evidence on whether screening asymptomatic adults for CHD with resting or exercise ECG improves clinical outcomes, affects use of risk reduction therapies, or results in accurate reclassification into different risk categories. This report also systematically reviews the evidence on harms associated with screening. In addition to including new evidence, this report differs from earlier USPSTF reviews by focusing on studies that assessed the usefulness of screening after adjusting for traditional cardiovascular risk factors, in order to better understand the incremental value of resting or exercise ECG. In addition, we performed meta-analysis on the association between selected resting and exercise ECG abnormalities and subsequent cardiovascular events.

Condition Definition

CHD refers to atherosclerosis of the coronary arteries. In patients with CHD, plaques form within the arteries, causing reduced blood flow and/or arterial blockage. Symptoms of CHD include angina, shortness of breath, and fatigue. However, even high-grade atherosclerosis can be present with no accompanying symptoms. Conversely, CHD events can occur even when only mild-grade atherosclerosis is present. Serious CHD events include MI, stroke, heart failure, and sudden cardiac death.

Prevalence and Burden of Disease

The average annual incidence of first major cardiovascular event increases with older age, from around 7 cases per 1,000 in men ages 35–44 years to 68 cases per 1,000 in men ages 85–94 years. For women, similar incidence rates are observed about 10 years later in life, though the gap narrows with advancing age. Disparities exist with regard to mortality from CHD. Mortality rates are lowest for white women and highest for black men. CHD is a major source of direct and indirect health care costs in the United States. In 2010, projected CHD-related costs were $316 billion.1

Etiology and Natural History

CHD is a disease of the coronary arteries, which provide oxygenated blood to the myocardium. CHD typically develops over many years with the deposition of atherosclerotic plaque within the endothelial lining of the epicardial coronary arteries, in conjunction with some degree of inflammation. Atherosclerotic plaque tends to develop focally and often in predisposed segments of the coronary arteries, often at branch points. Acute coronary syndrome, MI, and sudden cardiac death are often associated with plaque rupture and/or intravascular thrombosis associated with plaque and/or plaque rupture. In general, CHD is a progressive disease, although the risk of progression can be reduced by addressing modifiable risk factors (see below). CHD is the leading cause of death in the United States.

Significant CHD has often been considered to be present in individuals who have either experienced a coronary event or who have highly stenotic coronary vessels as evaluated by coronary angiography. However, acute coronary events often occur in vessels that are not severely stenotic, as a consequence of plaque rupture or acute thrombosis. Thus, how to identify CHD among individuals without objective clinical evidence of disease is a challenge, since plaque rupture leading to acute coronary events is not necessarily limited to coronary arteries with a high degree of narrowing. This concept has important implications for screening because most markers for CHD on resting and exercise ECG are probably related to the presence of significant coronary artery stenosis. It also has implications for treatment in individuals identified as being at higher risk. Although such individuals might benefit from treatment of modifiable risk factors, they might not necessarily benefit from revascularization procedures.

Risk Factors

Traditional risk factors for CHD (i.e., those included in Framingham risk models) are male sex, older age, tobacco use, hypertension, dyslipidemia (high total or LDL cholesterol or low HDL cholesterol), and diabetes. Other risk factors for CHD include family history of early CHD, obesity, physical inactivity, atherogenic diet, and presence of prothrombic and proinflammatory factors. Some risk factors are modifiable, and could be targets for treatment in patients identified as being at higher risk. As of 2003, over one third of all American adults have two or more risk factors for CHD, although rates varied according to age, race, and socioeconomic group.9 Nearly all CHD events (~90 percent) occur in people with at least one risk factor, and the presence of any risk factor at age 50 years—even those of borderline clinical significance—substantially increases the lifetime risk of experiencing a CHD event.10,11

Rationale for Screening/Screening Strategies

Many patients with CHD do not present with symptoms prior to experiencing a significant first CHD event such as sudden cardiac arrest, MI, congestive heart failure (CHF), or unstable angina. In fact, based on observational data, symptoms suggestive of CHD are less accurate than traditional risk factors for predicting 5-year mortality.12 For screening to be clinically useful, it should provide information beyond that available from assessment of traditional risk factors, which are available to clinicians from demographic information and clinical history. Screening could identify individuals with subclinical CHD who might benefit from earlier or more aggressive treatment of modifiable risk factors, or might be candidates for other treatments (such as revascularization). For risk classification strategies to be effective, screening would ideally accurately stratify individuals into low-, intermediate-, and high-risk groups in order to best guide the use of preventive and other measures.


Commonly used tests for detecting asymptomatic CHD include resting and exercise ECG. Although the most common method of exercise testing is the exercise treadmill test (ETT), other methods include bicycles and ergometers. Both resting and exercise ECG may show markers of unrecognized previous MI, silent or inducible myocardial ischemia, and other cardiac abnormalities (such as left ventricular hypertrophy [LVH], bundle branch block, or arrhythmia) that may be associated with CHD or predict future CHD events. Other screening tests for CHD include the ankle-brachial index, B-mode carotid Doppler ultrasonography, and cardiac computed tomography (CT), a noninvasive imaging examination for coronary artery atherosclerosis. Most of these tests are considered in other USPSTF reviews.13–15

Current Clinical Practice

Resting or exercise ECG screening in low-risk patients is not recommended by any organization (see below). Evidence on current clinical use of resting or exercise ECG to screen asymptomatic patients for CHD is sparse, but anecdotally is performed with some frequency. Routine cardiovascular risk factor screening after age 35 years in men and age 45 years in women, with the goal of addressing modifiable risk factors, is recommended by the American College of Cardiology Foundation and the American Heart Association (AHA).16 Risk factor screening typically involves using Framingham or other risk prediction tools based on the presence of clinical risk factors.

Recommendations of Other Groups

Numerous organizations recommend against routine screening of asymptomatic adults for CHD with resting or exercise ECG, including the American College of Physicians, American Academy of Family Physicians (AAFP), American College of Cardiology, AHA, American College of Preventive Medicine, and American College of Sports Medicine (ACSM).17–22 Screening of special populations is recommended by some groups. For example, AAFP recommends screening otherwise low-risk patients who have certain occupations in which undetected CHD could significantly impact the public (e.g., airline pilots), and ACSM recommends screening moderate-risk patients who are beginning a new exercise regimen.22,23

Previous USPSTF Recommendation

In 2004, the USPSTF recommended against routine screening with resting ECG or ETT for either the presence of severe coronary artery stenosis or the prediction of CHD events in adults at low risk for CHD events (D recommendation). The USPSTF found insufficient evidence to recommend for or against routine screening with ECG or ETT for either the presence of severe coronary artery stenosis or the prediction of CHD events in adults at increased risk for CHD events (I statement).

Cover of Screening Asymptomatic Adults for Coronary Heart Disease With Resting or Exercise Electrocardiography
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 [Internet].
Evidence Syntheses, No. 88.
Chou R, Arora B, Dana T, et al.


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