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
- Section Editor
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
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.
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 "Cardiovascular disease risk assessment for primary prevention: Our approach".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J 1986; 111:383.
- Greenland P, Gaziano JM. Clinical practice. Selecting asymptomatic patients for coronary computed tomography or electrocardiographic exercise testing. N Engl J Med 2003; 349:465.
- Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300:1350.
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012; 60:e44.
- Cheng VY, Berman DS, Rozanski A, et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational coronary CT angiography evaluation for clinical outcomes: an international multicenter registry (CONFIRM). Circulation 2011; 124:2423.
- Diamond GA, Hirsch M, Forrester JS, et al. Application of information theory to clinical diagnostic testing. The electrocardiographic stress test. Circulation 1981; 63:915.
- Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2010; 122:2748.
- American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription, 9th Edition. Pescatello LS, Arena R, Riebe D, Thompson PD, eds. Lippicott Williams & Wilkins. 2014.
- Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 63:380.
- Siscovick DS, Ekelund LG, Johnson JL, et al. Sensitivity of exercise electrocardiography for acute cardiac events during moderate and strenuous physical activity. The Lipid Research Clinics Coronary Primary Prevention Trial. Arch Intern Med 1991; 151:325.
- Thomas GS, Voros S, McPherson JA, et al. A blood-based gene expression test for obstructive coronary artery disease tested in symptomatic nondiabetic patients referred for myocardial perfusion imaging the COMPASS study. Circ Cardiovasc Genet 2013; 6:154.
- Rosenberg S, Elashoff MR, Beineke P, et al. Multicenter validation of the diagnostic accuracy of a blood-based gene expression test for assessing obstructive coronary artery disease in nondiabetic patients. Ann Intern Med 2010; 153:425.
- Elashoff MR, Wingrove JA, Beineke P, et al. Development of a blood-based gene expression algorithm for assessment of obstructive coronary artery disease in non-diabetic patients. BMC Med Genomics 2011; 4:26.
- Vargas J, Lima JA, Kraus WE, et al. Use of the Corus® CAD Gene Expression Test for Assessment of Obstructive Coronary Artery Disease Likelihood in Symptomatic Non-Diabetic Patients. PLoS Curr 2013; 5.
- Moyer VA, U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 157:512.
- Chou R, High Value Care Task Force of the American College of Physicians. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med 2015; 162:438.
- Daviglus ML, Liao Y, Greenland P, et al. Association of nonspecific minor ST-T abnormalities with cardiovascular mortality: the Chicago Western Electric Study. JAMA 1999; 281:530.
- De Bacquer D, De Backer G, Kornitzer M, et al. Prognostic value of ischemic electrocardiographic findings for cardiovascular mortality in men and women. J Am Coll Cardiol 1998; 32:680.
- Chou R, Arora B, Dana T, et al. Screening asymptomatic adults with resting or exercise electrocardiography: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 155:375.
- Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation 1983; 68:939.
- Rose G, Baxter PJ, Reid DD, McCartney P. Prevalence and prognosis of electrocardiographic findings in middle-aged men. Br Heart J 1978; 40:636.
- Mahmarian JJ, Steingart RM, Forman S, et al. Relation between ambulatory electrocardiographic monitoring and myocardial perfusion imaging to detect coronary artery disease and myocardial ischemia: an ACIP ancillary study. The Asymptomatic Cardiac Ischemia Pilot (ACIP) Investigators. J Am Coll Cardiol 1997; 29:764.
- Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation 1989; 80:87.
- Rautaharju PM, Prineas RJ, Eifler WJ, et al. Prognostic value of exercise electrocardiogram in men at high risk of future coronary heart disease: Multiple Risk Factor Intervention Trial experience. J Am Coll Cardiol 1986; 8:1.
- Ekelund LG, Suchindran CM, McMahon RP, et al. Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: the Lipid Research Clinics Coronary Primary Prevention Trial. J Am Coll Cardiol 1989; 14:556.
- Gibbons LW, Mitchell TL, Wei M, et al. Maximal exercise test as a predictor of risk for mortality from coronary heart disease in asymptomatic men. Am J Cardiol 2000; 86:53.
- Rywik TM, Zink RC, Gittings NS, et al. Independent prognostic significance of ischemic ST-segment response limited to recovery from treadmill exercise in asymptomatic subjects. Circulation 1998; 97:2117.
- Roger VL, Jacobsen SJ, Pellikka PA, et al. Prognostic value of treadmill exercise testing: a population-based study in Olmsted County, Minnesota. Circulation 1998; 98:2836.
- Laukkanen JA, Kurl S, Lakka TA, et al. Exercise-induced silent myocardial ischemia and coronary morbidity and mortality in middle-aged men. J Am Coll Cardiol 2001; 38:72.
- Deedwania PC. Silent ischemia predicts poor outcome in high-risk healthy men. J Am Coll Cardiol 2001; 38:80.
- Blumenthal RS, Becker DM, Moy TF, et al. Exercise thallium tomography predicts future clinically manifest coronary heart disease in a high-risk asymptomatic population. Circulation 1996; 93:915.
- Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003; 290:1600.
- Hecht HS. Coronary artery calcium scanning: past, present, and future. JACC Cardiovasc Imaging 2015; 8:579.
- Haberl R, Becker A, Leber A, et al. Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients. J Am Coll Cardiol 2001; 37:451.
- Nallamothu BK, Saint S, Bielak LF, et al. Electron-beam computed tomography in the diagnosis of coronary artery disease: a meta-analysis. Arch Intern Med 2001; 161:833.
- Rozanski A, Gransar H, Shaw LJ, et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) prospective randomized trial. J Am Coll Cardiol 2011; 57:1622.
- Osawa K, Nakanishi R, Budoff MJ. Is there a role for coronary artery calcification scoring in primary prevention of cerebrovascular disease? Atherosclerosis 2017; 257:279.
- Muhlestein JB, Lappé DL, Lima JA, et al. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA 2014; 312:2234.
- Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) developed in collaboration with the Society for Cardiac Angiography and Interventions. Circulation 1999; 99:2345.
- Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40:1531.
- Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015; 372:1291.
- Williams MC, Hunter A, Shah AS, et al. Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease. J Am Coll Cardiol 2016; 67:1759.
- Bittencourt MS, Hulten EA, Murthy VL, et al. Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis. Circ Cardiovasc Imaging 2016; 9:e004419.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123.
- Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44.
- 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