Lifelong Health: Cardiac stress tests are often performed too frequently
Annually, hundreds of thousands of healthy Americans have a stress test to screen for coronary artery disease. The stress test can be done in one of two ways. The heart can either be stressed by exercising on a treadmill or by injecting a radioisotope and scanning the heart before and after exercise. If exercise is difficult, the heart can be stressed by injecting the medication Persantine. In either case, abnormalities can identify coronary artery disease. Frequently, the heart is monitored during the stress test using both an EKG and an echocardiogram.
Recently, the United States Preventative Services Task Force reaffirmed the opinion of many experts that there was no value in doing routine EKG’s and stress tests in healthy individuals at low risk of having heart disease and who have no symptoms suggesting a heart problem such as chest pain or shortness of breath. They do so because the tests often yield false results leading to needless additional investigations that may cause more harm than good. Furthermore, a normal test is not a good predictor of future risk of cardiac problems.
Even for those at higher risk of heart disease, the task force does not believe there is enough evidence either for or against EKG and stress testing and suggest that a decision be made on a case-by-case basis between doctor and patient.
So how do you determine your risk for having a heart attack? This can easily be accomplished by entering information into a risk assessment tool developed by the American Heart association, which is available on the Internet (www.heart.org). Their heart attack risk calculator factors in the common conditions that contribute to a higher chance of having a heart attack including age, being a male or post-menopausal female, a strong family history of heart attacks, high blood pressure, an elevated total and LDL (bad) cholesterol, a fasting blood sugar greater than 100, smoking, being overweight, sedentary and eating poorly. Once completed, the tool provides information of the risk of having a heart attack within 10 years and what steps should be taken to address any problems.
As heart disease is clearly the leading cause of death, it is fair to assume that everyone is in danger of problems, and therefore attempts at preventing heart attacks are far more important and valuable than finding out during a stress test that significant coronary artery disease is already present.
This involves compulsively living a heart-healthy lifestyle, including exercise, eating right, smoking cessation and stress management as well as working closely with your doctor to identify and correct treatable risk factors.
If heart attack risk is moderate or high, a dialogue with a primary care physician or cardiologist to determine if a stress test should be done is appropriate. And for someone whose assessment indicates a very high risk of a heart attack within the next 10 years, a screening stress test is a realistic consideration. There must be an understanding that the result may lead to angiograms and angioplasty and even open-heart surgery.
No matter your risk, should symptoms develop, such as shortness of breath or chest pain, a stress test is then used as a diagnostic rather than a screening tool. Some experts may even forgo a stress test and opt for an immediate angiogram if symptoms are sufficiently compelling.
For anyone known to have coronary artery disease, who is being optimally managed with medications and who either has no or stable symptoms, annual stress tests may do more harm than good. In this circumstance, any invasive procedure to open a blocked artery (either by angioplasty using stents or surgery) will neither prolong life nor reduce the risk of a heart attack. Invasive procedures will relieve symptoms, but sadly angiograms and even open-heart surgery are often done on individuals with no symptoms at all.
Nothing is scarier than dealing with a heart problem. The evidence is compelling that aggressive diagnostic and invasive procedures are highly effective when done for the appropriate indication. But numerous studies have shown that this aggressive care is frequently unnecessary and can cause more harm than good. In relation to heart health, the more you know, the more involved you are in your care, the better.
Dr. David Lipschitz is the director of The Longevity Center at St. Vincent Infirmary Medical Center. To find out more about Dr. David Lipschitz and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at http://www.creators.com. More information is available at: DrDavidHealth.com.
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