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