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Screening for Asymptomatic Coronary Artery Disease: a Systematic Review for the U.S

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Screening for Asymptomatic Coronary Artery Disease: a Systematic Review for the U.S This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products m ay not be stated or implied. AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers— patients and clinicians, health system leaders, and policymakers—make more informed decisions and improve the quality of health care services. Systematic Evidence Review Number 22 Screening for Asymptomatic Coronary Artery Disease: A Systematic Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 http://www.ahrq.gov Contract No. 290-97-0011 Task Order No. 3 Technical Support of the U.S. Preventive Services Task Force Prepared by: Research Triangle Institute-University of North Carolina Evidence-based Practice Center Research Triangle Park, North Carolina Michael Pignone, MD, MPH * Angela Fowler-Brown, MD * Mark Pletcher, MD, MPH † Jeffrey A. Tice, MD † *Division of General Internal Medicine, University of North Carolina-Chapel Hill † Division of General Internal Medicine, University of California-San Francisco December 8, 2003 ii Preface The Agency for Healthcare Research and Quality (AHRQ) sponsors the development of Systematic Evidence Reviews (SERs) through its Evidence-based Practice Program. With ∗ guidance from the U.S. Preventive Services Task Force (USPSTF) and input from Federal partners and primary care specialty societies, the Evidence-based Practice Center at Oregon Health Sciences University systematically reviews the evidence of the effectiveness of a wide range of clinical preventive services, including screening, counseling, and chemoprevention, in the primary care setting. The SERs—comprehensive reviews of the scientific evidence on the effectiveness of particular clinical preventive services—serve as the foundation for the recommendations of the USPSTF, which provide age- and risk-factor-specific recommendations for the delivery of these services in the primary care setting. Details of the process of identifying and evaluating relevant scientific evidence are described in the “Methods” section of each SER. The SERs document the evidence regarding the benefits, limitations, and cost-effectiveness of a broad range of clinical preventive services and will help further awareness, delivery, and coverage of preventive care as an integral part of quality primary health care. AHRQ also disseminates the SERs on the AHRQ Web site (http://www.ahrq.gov/clinic/uspstfix.htm) and disseminates summaries of the evidence (summaries of the SERs) and recommendations of the USPSTF in print and on the Web. These are available through the AHRQ Web site and through the National Guideline Clearinghouse (http://www.ngc.gov). We welcome written comments on this SER. Comments may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 3000, Rockville, MD 20850, or e-mail [email protected]. Carolyn M. Clancy, M.D. Jean Slutsky, P. A., M.S.P.H. Director Acting Director Agency for Healthcare Research and Quality Center for Outcomes and Evidence Agency for Healthcare Research and Quality ∗The USPSTF is an independent panel of experts in primary care and prevention first convened by the U.S. Public Health Service in 1984. The USPSTF systematically reviews the evidence on the effectiveness of providing clinical preventive services--including screening, counseling, and chemoprevention--in the primary care setting. AHRQ convened the current USPSTF in November 1998 to update existing Task Force recommendations and to address new topics. iii The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service. iv Contents Introduction................................................................................................................................................... 2 Methods ........................................................................................................................................................ 4 Results........................................................................................................................................................... 5 Effect of Screening Tests on Health Outcomes ............................................................................... 5 Effect of Screening on Adoption of Risk-reducing Behaviors ........................................................ 6 Effect of Screening on Risk of Future CHD Events ........................................................................ 7 Resting Electrocardiogram (ECG)...................................................................................... 7 Exercise Treadmill Testing (ETT).................................................................................... 12 Electron Beam Computed Tomography (EBCT).............................................................. 16 Discussion................................................................................................................................................... 18 Acknowledgements .................................................................................................................................... 20 References................................................................................................................................................... 21 Appendix..................................................................................................................................................... 28 Figure and Tables Figure 1. Analytic Framework: Screening for Asymptomatic Coronary Artery Disease ............... 30 Table 1A. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: Q Waves.......................................................... 31 Table 1B. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: Left Ventricular Hypertrophy.......................... 32 Table 1C. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: ST Segment Depression .................................. 35 Table 1D. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: T Wave Inversions .......................................... 37 Table 1E. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: Ventricular Ectopic Activity ........................... 38 Table 1F. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: Major ECG Changes ....................................... 39 Table 1G. Association between Resting ECG Abnormalities and Risk of Coronary Heart Disease Mortality in Asymptomatic Individuals: Minor ECG Changes ....................................... 40 Table 2. Association between Abnormal ST Segment Response to Exercise and CHD Events in Asymptomatic Individuals................................................................................................ 42 Table 3. Yield of Screening Tests under Different Assumptions about Pretest Probabilities and Sensitivity and Specificity Rates.....................................................................45 v Screening for Asymptomatic Coronary Artery Disease 1 Abstract Background: We reviewed the evidence on the value of screening asymptomatic patients with resting electrocardiogram (ECG), exercise electrocardiogram treadmill test (ETT), or electron beam computerized tomography (EBCT). Methods: We searched MEDLINE 1966 - June 2002 to identify studies examining the independent value of ECG, ETT, and EBCT in patients with no known history of cardiovascular events. We sought to identify studies that examined the use of these tests compared with traditional risk assessment of coronary heart disease (CHD) as a means of reducing CHD events, improving the use of CHD risk-reducing treatments, or producing more accurate assessments of actual CHD risk. Results: No studies examined the effect of screening asymptomatic patients with ECG, ETT, or EBCT on CHD outcomes. Two fair quality studies examined the effect of a positive EBCT on self-reported adoption of risk-reducing behaviors and found mixed results. ECG, ETT, and EBCT each can provide independent prognostic information about the risk of CHD events, mainly in middle-aged or older adults, but the effect of this information on clinical decisionmaking is unclear. When the risk of CHD events is low, however, most positive findings will be false positives and may result in unnecessary further testing.
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