“Should You Get A Routine Annual Electrocardiogram?”, Revisited

Four years ago the skeptical cardiologist wrote a post which outlined the reasons why most people should avoid getting a routine annual electrocardiogram.

I pointed out that

If you …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.

Yesterday, the USPSTF published an updated analysis which confirmed this recommendation:

The U.S. Preventive Services Task Force (USPSTF) recommends against preventative screening with resting or exercise electrocardiography (ECG) in asymptomatic adults at low risk of cardiovascular disease events in an updated recommendation statement published June 12 in the Journal of the American Medical Association (JAMA).

I should point out that I still believe (although some would disagree) screening for atrial fibrillation with methods other than a 12-lead ECG (including taking the pulse or checking a single lead ECG with a Kardia device) is worthwhile.

Below, I’ve reposted relevant sections of my 2014 post which emphasizes the problem of false positives and false negatives which are quite frequent with any screening test but are particularly worrisome with the routine 12-lead ECG.

 


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 adverse 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.

12 lead ECG routinely performed prior to surgery and interpreted by computer as ASMI or anteroseptal myocardial infarction ( heart attack).Patient with totally normal heart. Often such false positives are due to poor placement of the ECG leads

False positives lead to unnecessary worry, anxiety, and testing. More testing is highly 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.

Skeptically Yours,

-ACP

h/t Jerry , the life coach of the skeptical cardiologist , who originally posed this question to me.

 

4 thoughts on ““Should You Get A Routine Annual Electrocardiogram?”, Revisited”

  1. Wow—this kind of hits home—I’m 58, and my roller coaster ride through the Cardiology dept. started exactly 4 years ago with a “routine” pre-op physical for a meniscus tear in my right knee. My PCP did a routine ECG and surprise—it showed I had left ventricular hypertrophy. A stress ECG was done and confirmed what the 1st ECG showed, and I was referred to a cardiologist. He ordered an echocardiogram, which came back normal, but did show “borderline” LVH. I was already on Lipitor and aspirin therapy due to family history, And was put on Lisinopril to optimize my blood pressure. Since then, I have had a CT angiogram ( at my insistence) which showed a very poor 314 calcium score, another echo, a stress echo, and a holter monitor (all done in 2016 after developing heart palpitations and a “pounding” heart”. (Apparently I now have an A/V block type 2 first degree) The cherry on top was a catheter angiogram in 10/2016 after an esophageal spasm took me to the ER. The ER doc said I was having a heart attack—thankfully, I wasn’t, and the angiogram only showed mild plaque burden. And here I thought I was healthy! Lifelong vigorous exerciser. Historically good cholesterol numbers. For me, all this testing has been a mixed bag, but added stress and worry has definitely been a big part of it. But bottom line, none of it really changed treatment protocol one bit. Aspirin, Lipitor, Valsartan, along with continued vigorous exercise and cleaning up my diet a bit more. Are you taking new patients?? I think I need a fresh set of eyes to look all this over. As always, love all the information you put out as well as your take. Thank you!

  2. The same applies to regular PSA (blood) testing.
    A high reading will result in biopsies, – many needles perforating the prostate via the rectum. How many ? Pick any number between 3 and 12…after all, the “cancerous” cells are tiny, and a single needle is not likely to hit it!. My GP agrees that his middle finger is still the best detector;- after symptoms are reported.
    It is still true that most men die WITH some prostate cancer, and if PC kills me at age 90+ I’ll be happy with that !
    A woman with dense breast tissue needs a much higher X-Ray dose to simply get through. Is the extra risk superior to her self-examination?

  3. We are the most overdoctored, overmedicated society on earth, and as with everything else, there is such a thing as too much prevention, finding stuff that doesn’t exist and occasionally, as you say, not finding stuff that does.

    Wellness vendors, needless to say, are the worst offenders, combining complete lack of understanding of biostatistics with breathless excitement when they get to employees how sick they are, and tell employers how many sick employees they have.

    It’s not overdiagnosis. It’s hyperdiagnosis. https://theysaidwhat.net/2015/07/17/hyperdiagnosis-the-wellness-industrys-anti-employee-jihad/

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