Screening for coronary heart disease
- Pamela S Douglas, MD
Pamela S Douglas, MD
- Ursula Geller Professor of Research in Cardiovascular Diseases
- Duke University Medical Center
Although mortality from coronary heart disease (CHD) has fallen substantially in many countries, CHD remains the leading cause of death in adults in developed countries and is a rapidly increasing cause of death for adults in developing countries. (See "Epidemiology of coronary heart disease".)
There is considerable interest in the diagnosis of CHD when patients are still asymptomatic and prior to the development of hard endpoints (eg, myocardial infarction, sudden cardiac arrest), which are associated with significant morbidity and mortality. However, questions persist regarding the appropriateness and cost effectiveness of screening for CHD along with the optimal approach to screening. This is largely due to the lack of evidence that screening for CHD can improve outcomes more than obtaining a CHD risk assessment and implementing appropriate primary preventive measures aimed at known CHD risk factors. (See "Estimation of cardiovascular risk in an individual patient without known cardiovascular disease".)
The issues surrounding screening for CHD will be reviewed here, with particular emphasis on the effectiveness of available screening methodologies. Screening for CHD in patients with diabetes, generally a higher-risk population, is discussed in detail separately. (See "Screening for coronary heart disease in patients with diabetes mellitus".)
RATIONALE FOR SCREENING
Advanced obstructive coronary heart disease (CHD) can exist with minimal or no symptoms, with manifestations that can progress suddenly and/or rapidly. The first clinical manifestation of CHD, acute myocardial infarction (MI), unstable angina, or sudden cardiac death, is often associated with significant morbidity and/or mortality . The rationale for early detection of CHD is that detection during the subclinical stages of disease might permit the reliable identification of subjects at increased risk of an adverse cardiac event and that appropriate therapy (eg, lipid lowering) might improve the prognosis of those at high risk . Other rationales for screening include certain high-risk occupations (eg, pilots, bus drivers, etc) where an acute cardiac event could endanger large numbers of people, or individuals with higher perceived risk of CHD who are beginning an exercise program. Although screening can identify patients with CHD at increased risk, there is a paucity of evidence that such screening actually improves outcomes. (See 'Intervening following screening' below.)
Purpose of screening — The primary purpose of screening for CHD is to identify patients whose prognosis could be improved with an intervention (in this case, medical therapy for risk factors or coronary revascularization). Screening for CHD should be distinguished from estimation of risk for CHD (or overall cardiovascular disease [CVD]). By definition, both are performed in asymptomatic persons, and both aim to improve outcomes with interventions, if indicated. However, screening for CHD (or CVD) identifies existing disease, while estimating the risk of CHD (or CVD) does not directly identify existing disease but rather the likelihood of any future event related to CHD (or CVD). (See "Estimation of cardiovascular risk in an individual patient without known cardiovascular disease".)
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- RATIONALE FOR SCREENING
- Purpose of screening
- Bayesian considerations
- OUR APPROACH
- History and physical examination
- Who should be screened?
- Special populations
- - Pre-participation testing
- - Public safety occupations, high risk occupations, and high risk avocations
- AVAILABLE SCREENING TESTS AND THEIR USE IN ASYMPTOMATIC INDIVIDUALS
- Blood tests
- Resting ECG and ambulatory ECG monitoring
- Stress testing
- Coronary calcium score and CT angiography
- Invasive coronary angiography
- RECOMMENDATIONS FROM MAJOR SOCIETIES
- FOLLOW-UP OF A POSITIVE SCREENING TEST
- Intervening following screening
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS