Should You Get a Routine Annual Electrocardiogram (ECG)?

Recently, the skeptical cardiologist  was asked by his  old friend and life coach (OFALCSC) whether he was correct to refuse the annual electrocardiogram (ECG) which his primary care doctor had recommended during an annual physical.

ECG showing atrial fibrillation
ECG showing atrial fibrillation

Most of my patients feel that the ECG has the ability to tell me  quite a bit about their heart. The technique utilizes electrodes on the arms, legs and chest region which  record with precision, the depolarization and repolarization of the upper chambers (atria) and lower chamber (ventricles) of the heart.

The ECG is THE tool for assessing the rhythm of the heart.  If performed and interpreted properly (not always a given) it tells us very precisely whether we are in normal (sinus) rhythm, wherein the atria contract synchronously before the ventricles contract, or in an abnormal rhythm. It is also very good at telling us whether you are having a heart attack.

If you are, however, like the OFALSC, and feel fine (meaning without symptoms or asymptomatic), exercise regularly, have never had heart problems,  and have a pulse between 60 and 90, the value of the routine annual ECG is very questionable. In fact, the United States Preventive Services Task Force (USPFTF)

“recommends against screening with resting or exercise electrocardiography (ECG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events”

(for asymptomatic adults at intermediate or high risk for CHD they deem the evidence insufficient). The USPSTF feels that that the evidence only supports an annual BP screen along with measurement of weight and a PAP smear.

To many, this seems counter-intuitive: how can a totally benign test that has the potential to detect early heart disease or abnormal rhythms not be beneficial?

There is a growing movement calling for restraint and careful analysis of the value of all testing that is done in medicine. Screening tests, in particular are coming under scrutiny.
Even the annual mammogram, considered by most to be an essential tool in the fight against breast cancer, is now being questioned.

My former cardiology partner, Dr. John Mandrola, who writes the excellent blog at http://www.drjohnm.org, has started an excellent discussion of a recent paper that shows no reduction of mortality with the annual mammogram. He looks at the topic in the context of patient/doctor perception that “doing something” is always better than doing nothing, and the problem of “over-testing.”

In my field of cardiology there is much testing done. It ranges from the (seemingly) benign and (relatively) inexpensive electrocardiogram to the invasive and potentially deadly cardiac catheterization. For the most part, if patients don’t have to pay too much, they won’t question the indication for the tests we cardiologists order. After all, they want to do as much as possible to prevent themselves  from dropping dead from a heart attack and they reason that the more testing that is done, the better, in that regard.

The Problem of False Positives and False Negatives

But all testing has the potential for negative consequences because of the problem of false positives and negatives. To give just one example: ECGs in people with totally normal hearts are regularly interpreted as showing a prior heart attack. This is a false positive. The test is positive (abnormal) but the person does not have the disease. At this point, more testing is likely to be ordered; specifically, a stress test. Stress tests in low risk, asymptomatic individuals often result in false positive results. After a false positive stress test, it is highly likely that a catheterization will be ordered. This test carries potential risks of kidney failure, heart attack, stroke and death. It is bad enough that the cascade of testing initiated by an abnormal, false positive,  screening test results in unnecessary radiation, expense and bother but  in some cases it end up killing patients rather than saving lives.

On the other end of the spectrum is the false negative ECG. Most of my patients believe that if their ECG is normal then their heart is OK. Unfortunately the ECG is very insensitive to cardiac problems that are not related to the rhythm of the heart or an acute heart attack.

Patients who have 90% blockage of all 3 of their major coronary arteries and are at high risk for heart attack often have a totally normal ECG. This is a false negative. The patient has the disease (coronary artery disease), but the test is normal. In this situation the patient may be falsely reassured that everything is fine with their heart. The next day when they start experiencing chest pain from an acute heart attack, they may dismiss it as heart burn instead of going to the ER.

More and more, screening tests like the ECG and the mammogram  are rightfully being questioned by patients and payers. For a more extensive discussion about which tests in medicine are appropriate check out the American Board of Internal Medicine’s http://www.choosingwisely.org.

Keep in mind: not uncommonly,  doing more testing can result in worse outcomes than doing less.

5 thoughts on “Should You Get a Routine Annual Electrocardiogram (ECG)?”

  1. Your point about the dangers of too much testing, of overtreatment, and of medicalizing otherwise healthy people is spot-on. A false positive stress test is both disheartening (pardon the pun) and dangerous to the patient, as you describe. A previously healthy person falls down the hole of unnecessary medicalization, is labeled a “heart patient,” and is put on the conveyor belt of referrals, tests, prescriptions, and follow-up visits. Now, on top of anxiety over what lies ahead (PCI, bypass, a half-dozen medications), they’re left to cope with the stigma of being a heart patient. In addition to the risks inherent in a trip to the cath lab, that person’s identity is changed and their sense of health might just be destroyed. I highly recommend Nortin Hadler’s book “Worried Sick” if you haven’t read it already. Your blog has a new subscriber.

  2. I’m a 32 year old female, no heart disease risk…I do have MS and was getting all my pre screening for a new medication and my ECG’s keep showing “old anterior mi”. My treatment is now put off until this all gets figured out. I do have episodes, randomly, of very fast HR which according to doctors are panic attacks or SVT.
    Apparently an ECG I had done in the ER (I went for fast HR) over a year ago also showed “old anterior mi” no one informed me then. My fast HR episodes and palpitations have increased significantly since finding out about the heart attack I have no recollection of having.

    Basically, I just wanted to let you know this blog post gave me some relief, and I’ve also been reading the other posts, I don’t understand most of it…..I probably do need more potassium though.

  3. Lol, I know this is old but it made me laugh. I recently had stents fail and had an ECG mid-heart attack. Came out normal. I had a 99percent blockage where the stents were clotted. Nuclear stress test normal. I’ve had 3 prior heart attacks. All my EKGs normal. Hours and hours of telemetry at the hospital were normal. My doctors at the hospital were clearly nervous around me. My cardiologist called me “mysterious.”

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