The myth about screening for heart disease

The myth about screening for heart disease
An excerpt from 
The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy.

In the spring of 2008, NBC’s Meet the Press moderator and Washington bureau chief, Tim Russert, died suddenly of a heart attack at the age of fifty-eight. Time magazine identified him as one of the one hundred most influential people in world in 2008. His ability to make complex topics clear for the public and to ask the hard questions will be missed.

Perhaps more shocking was that just a few weeks earlier, he had passed a cardiac stress test.

In other words, the stress test was normal.

This is one of the biggest myths that must be dispelled about screening for heart disease. In patients with no symptoms, screening for heart disease with heart stress tests such as treadmills or using EKGs has not been shown to save lives. These tests are far more beneficial in evaluating patients with symptoms of chest pain, shortness of breath, palpitations, or other symptoms that might be related to the heart. Yet this message is not being heard. A 2011 article from Consumer Reports found in a survey of over eight thousand subscribers between the ages of forty and sixty who had no history or symptoms of heart disease that about half had undergone an EKG and one out of five had taken a heart stress test.

In patients at little to low risk for heart disease, an EKG or stress testing can actually lead to harm. The heart stress test can be a false positive; that is, the test can detect an abnormality which then has to be further investigated with either a nuclear medicine scan or a CT angiogram, both of which require radiation exposure. In patients at little to low risk, the subsequent results are normal, as one would expect. The patient went through unnecessary worry and testing. There can be too much of a good thing.

In the case of Mr. Russert, who was at higher risk of heart disease due to his age, gender, and other risk factors, passing a cardiac stress test also shows the limitation of these tools. They do not work well in predicting the risk of heart attack in patients with no symptoms. Be aware of this limitation before someone recommends this type of testing, particularly when you feel well.

Consumer Reports has an excellent app that helps you determine which interventions are best in screening for heart disease.

The boring, unsexy task of controlling cholesterol and high blood pressure were rated the best and highest. The benefits far outweighed any of the risks. One of the worst interventions, where the risk outweighed the benefit? The heart stress test.

As you pay more out of pocket for health care, isn’t important to know what is and what isn’t worth your hard-earned money?

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Steven Reznick

    Evaluating cardiovascular risk starts with taking a good health history and doing a thorough exam. There are a multitude of major and minor cardiovascular risk factors that can be identified and addressed during the history session. Dealing with the major risks like smoking, blood pressure control, diabetes, lipid management , activity level is still where the bulk of the well spent health dollar is. Based on your exam determining who should be further evaluated is the true art and skill. There are groups at the Cleveland Clinic who talk about the large number of men who have their first heart attack or stroke despite having minimal or low risks if any. They have developed their own inflammatory screening protocal through Dr Bale and Amy Doneen’s work to find those low risk but at risk patients and then modify their risks. Yes traditional stress testing, stress echos, cardiac calcium scoring all have their limitations. When the appropriate evaluation is done by physicians who understand the limitations of the screening procedure the yield is usually higher..This is why blanket imaging screening is so cost ineffective.

  • Shirie Leng

    Fantastic! People don’t realize that there is a good possibility that testing when you are healthy leads to more testing, then worry, then some sort of invasive procedure, when really nothing is wrong with you. We as a society need to use the data available to us to limit screening to the patients in which it would do the most good.

    • davisliumd

      Completely agree! Challenge is having the right conversations to do the right thing, understand a patient’s palpable fear or worry, and address their symptoms!

  • SBornfeld

    Can we do a little better than quoting Consumer Reports?

    • james ehrlich md

      agree….consumer reports????

  • Peter Whitehouse

    OK – but what could have predicted Mr Russert’s heart attack if not a treadmill or an EKG? Anything at all?

    • james ehrlich md

      see my post….coronary calcium test

  • james ehrlich md

    In 1998, a full ten years before his fatal event, my cardiovascular risk assessment center (HeartScan Washington DC) correctly diagnosed Mr. Russert (age 48 at that time) as being at very high risk using Electron Beam Tomography calcium scanning–the most powerful predictor of future cardiovascular risk. Mr. Russert had metabolic syndrome and “intermediate risk” and was correctly referred by his internist, an excellent doctor. What i can reveal (public knowledge) is that Mr Russert had more plaque than 93% of men his age back then. I agree with Mr. Liu that a stress test (which only becomes positive when there is a 70% blockage is not useful for asymptomatic screening of heart disease…it is non-obstructive vulnerable plaque that kills most of us. In fact about 80% of apparently healthy people who die suddenly from an MI would have passed their stress tests (including nuclear) in the weeks prior to their fatal event. I do not agree that the Consumer Reports app is worthwhile…they don’t even mention calcium scanning. The expert consensus guidelines of the American Heart Association and American College of Cardiology would favor such testing in “intermediate risk” patients—so forget Consumer reports !!

    By the way, in an interview with Barbara Walters, Luke Russert discussed the inadequacies of a treadmill was repeatedly normal.

    The lesson of Mr. Russert is that patients with atherosclerosis and the metabolic syndrome can have great “residual risk”—the risk we physicians leave behind even when LDL-C is below 70, as it was with Mr. Russert six weeks before his fatal event.

    Mr. Russert was a wonderful person

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