We identified no randomized trials that examined the effect of screening exercise tolerance testing to guide management and improve health outcomes of coronary heart disease or affect the use of risk-reducing treatments in asymptomatic adults. Exercise tolerance testing of asymptomatic persons rarely detects previously unrecognized, clinically important coronary artery obstruction (up to 2.7 percent of screened persons). It does provide some independent prognostic information in at least some persons (relative risk of about 2.0 to 5.0 for coronary heart disease events associated with an abnormal result) above and beyond the prognostic information that can be gained from traditional assessment of risk factors. The effect of this additional information on clinical decision making, however, has not been studied. The potential benefits of screening exercise tolerance testing are likely to be small for groups in which the prevalence of the disease is low, such as young adults; such screening would also produce many cases of false-positive results. In such cases, the costs and harms associated with additional testing may exceed any benefits from screening.
The value of screening exercise tolerance testing rests in large part on the underlying incidence of coronary heart disease events and the prevalence of serious artery obstructions in the screened sample. Exercise tolerance testing will probably perform better when applied to higher-risk groups, such as persons with 1 or more risk factors for coronary heart disease. Selection of a higher-risk group for screening increases the prevalence of disease in those screened and, thus, the predictive value of a positive test result. Whether the benefits of such tests exceed the disadvantages, including costs, in higher-risk groups is still unclear at present and requires investigation.
For persons at low risk for coronary heart disease events, a positive result on exercise tolerance testing is much more likely to be false positive than true positive. False-positive results in this context are concerning because they can lead to unnecessary, and possibly injurious, additional procedures.
Screening has been advocated for people with high-risk occupations, but we did not identify new studies on the effect of screening such patients. Data from studies of patients with known coronary heart disease but no ischemic symptoms suggest that treatment with medications, such as beta-blockers, or revascularization can improve outcomes over no treatment, but whether patients with no history of coronary heart disease would have the same results is unclear.77
Exercise tolerance testing can be normal or nondiagnostic in an important proportion of patients who will experience a coronary heart disease event, as evidenced by the sensitivity values of 10 percent to 74 percent in the studies that evaluated ST-segment depression as a risk marker (Table 3). In a defined cohort of low-risk patients, a larger absolute number of coronary heart disease events occurs among those with an initially normal result on exercise tolerance testing than among those with an initially abnormal result. The suboptimal sensitivity of ST-segment response for predicting coronary heart disease events may be explained in part by the fact that ST-segment depression on exercise tolerance testing detects ischemia from obstructed coronary arteries, but many acute coronary heart disease events result from sudden occlusion of a previously nonobstructed segment of artery.78 Use of other measures than the exercise test that are not as dependent on identification of atherosclerotic obstructions may mitigate this dilemma.79
The primary tangible harm of screening exercise tolerance testing is the potential for medical complications related to cardiac catheterization done to further evaluate a positive result. Coronary angiography is generally considered a safe procedure. Of all persons undergoing outpatient coronary angiography, however, an estimated 0.08 percent will die as a result of the procedure and 1.8 percent will experience a complication.80 Complications of coronary angiography include myocardial infarction, stroke, arrhythmia, dissection of the aorta and coronary artery, retroperitoneal bleeding, femoral artery aneurysm, renal dysfunction, and systemic infection. Rates of complications are likely to be somewhat lower in asymptomatic persons, but no good data are available. A positive result on exercise tolerance testing may also be an impetus to initiate risk-reducing therapy; hence, another potential harm of screening is use of therapies such as aspirin or statins to over-treat persons who would not otherwise require treatment (that is, would be considered low risk) if they did not have an abnormal result on exercise tolerance testing. Other potential harms, including the psychological consequences of a false-positive test result, also have not been well studied.
Our findings are consistent with those of the American Heart Association/American College of Cardiology expert panel, which also examined the effectiveness of screening exercise tolerance testing.33 They recommended against routine exercise tolerance testing in asymptomatic adults because of concerns about the positive and negative predictive value of screening exercise tolerance testing and the potential harms of false-positive results. The American Heart Association/American College of Cardiology found that screening exercise tolerance testing for persons with multiple risk factors to guide to risk-reduction therapy or for sedentary middle-aged adults who wish to start a vigorous exercise program is controversial but potentially beneficial.
Further studies are required to determine the balance of benefits and harms of screening exercise tolerance testing for patients with different degrees of risk for coronary heart disease. An adequately powered randomized trial of screening exercise tolerance testing compared with management based on traditional risk factors would greatly inform clinical decision making. Such a study should compare a traditional global coronary heart disease risk assessment tool to a screening strategy that also incorporates exercise tolerance testing. A broad spectrum of patients should be enrolled, including a sufficient number of women. Studies examining how providers and patients actually apply the additional information from exercise tolerance testing will also be helpful. Finally, better information about the adverse effects of screening is required if researchers are to perform well-informed cost-effectiveness analyses of exercise tolerance testing screening plus risk-factor-based decision making compared with risk-factor-based decisionmaking alone.
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This summary was prepared for AHRQ by the University of North Carolina at Chapel Hill, Chapel Hill, and RTI International, Research Triangle Park, NC; Cecil G. Sheps Center for Health Services Research, University of North Caroline, Chapel Hill, NC; and University of California, San Francisco, San Francisco, CA (contract 290-97-0011, task order 3).
The authors thank Jacqueline Besteman, J.D., Director of the Agency for Healthcare Research and Quality EPC Programs; David Atkins, M.D., M.P.H., Chief Medical Officer of the AHRQ Center for Practice Technology and Assessment; and Jean Slutsky, P.A., M.S.P.H., AHRQ Task Order Officer, for their assistance. They also thank Paul Frame, M.D., Tri-County Family Medicine, Cohocton, New York, and Carolyn Westhoff, M.D., M.P.H., Department of Obstetrics and Gynecology, Columbia University, New York, New York, who were the liaisons for the U.S. Preventive Services Task Force. Finally, they thank Tammeka Swinson, B.A., and Loraine Monroe of RTI International.
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Notes
Author Affiliations
[a] Fowler-Brown and Pignone: Division of General Internal Medicine, University of North Carolina at Chapel Hill, UNC Hospital, Chapel Hill, NC.
[b] Pletcher: Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA.
[c] Tice: Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA.
[d] Sutton and Lohr: RTI International, Research Triangle Park, NC.
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Fowler-Brown A, Pignone M, Pletcher M, Tice JA, Sutton SF, Lohr KN. Exercise Tolerance Testing to Screen for Coronary Heart Disease: A Summary of the Evidence for the U.S. Preventive Services Task Force. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/chd/chdsum1.htm
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