June 11, 2011

USA: Questions over cascade of unnecessary, costly and risky heart disease tests

NEW YORK, NY / The New York Times / Health / June 11, 2011

The Health Consumer

Some Heart Disease Screens May Be Unnecessary

By Walecia Konrad

HEART disease remains the No. 1 cause of death in the United States, killing more than 800,000 people each year, and accounting for one in three of all deaths. It is no wonder, then, that screening for heart disease is a routine part of just about every physical exam given in this country.


The number of these tests has increased significantly over the last 20 to 30 years, and these days screening may involve any of a dozen procedures — some as simple as taking a patient’s blood pressure, some as complicated as CT angiography, an expensive, controversial test that may carry health risks.


But as important as screening is, excessive and inappropriate testing can lead to “a cascade of unnecessary, costly and in some cases risky follow-up tests and treatment,” said Dr. John Santa, director of the health ratings center at Consumer Reports Health. “Many people who are screened will show signs of heart disease but will never actually suffer from the disease or a heart attack.”


Dr. John Santa, of Consumer Reports Health, says some cardiac screening is unwarranted and costly. Fred R. Conrad/The New York Times


When do you need to be screened for heart disease? What tests are worth having? Here is some advice from experts.

Step 1: In the absence of risk factors, rely on basic, not high-tech, screening tests.

Cost: Insurance should cover the cost as part of your annual physical. There may be some additional lab fees for blood work.

Patients without obvious symptoms of heart disease routinely receive blood pressure and cholesterol tests. Experts say both are relatively simple, inexpensive and worth your time.

High blood pressure, or hypertension, is commonly associated with heart disease and can cause stroke, heart failure and heart attack. Fortunately, the so-called silent killer is readily detectable. A doctor or nurse puts the cuff around your arm and inflates it until blood flow is cut off. As the cuff deflates, the doctor records the points at which blood can be heard to begin flowing again (the systolic pressure) and as it fully resumes (the diastolic pressure).

Health Guide: Heart Disease
Monitoring blood pressure is both useful and inexpensive.
Fred R. Conrad/The New York Times


A normal reading for a healthy person is below 140/90 millimeters of mercury. Any abnormal reading should be confirmed at least three times, as single readings can be misleading. Some patients experience an increase in pressure simply because they’re in the doctor’s office — “white coat hypertension,” it’s called.

A cholesterol screening, also called a fasting lipoprotein profile, helps doctors find coronary artery disease, the most common type of heart disease, and other artery diseases. C.A.D. occurs when fatty deposits, or plaque, choke off the flow of blood in arteries supplying the heart, weakening the muscle and often causing chest pain.

A simple test tells doctors your blood levels of total cholesterol, LDL (or “bad” cholesterol), HDL (“good” cholesterol) and fats called triglycerides. The test indicates a possible risk for heart disease if:

¶ Total cholesterol is above 200 milligrams per deciliter.
¶ HDL is below 40 milligrams per deciliter in men, or 50 milligrams per deciliter in women.
¶ LDL is above 130 milligrams per deciliter.
¶ Triglycerides are above 150 milligrams per deciliter.

The American Heart Association recommends that adults over age 20 receive a blood pressure screening at every doctor’s visit or at least once every two years. Cholesterol screenings should be given once every five years to men under age 45 and women under age 50 who have no other risks for heart disease.

Avoid: Several studies have suggested that expensive tests for biomarkers that are sometimes indicative of heart disease — such as C-reactive protein, a sign of systemic inflammation — are not cost-effective in generally healthy patients. More sophisticated testing should be done only in patients with known heart risks.

Step 2: If you are overweight or obese, get an annual fasting blood sugar test.

Cost: The test usually is included in an annual physical, although you may pay a small fee for lab work. Free diabetes screening often is available at health fairs and community centers.

People with Type 2 diabetes are far more likely than those without to develop heart disease — indeed, it is what kills most adults with diabetes. Up to a third of heart attack patients have diabetes, and 25 percent of heart attack patients have high blood sugar levels.

The test measures levels of blood sugar, or glucose, which is the body’s fuel. A reading of 126 milligrams per deciliter or higher signals a problem. Again, you should undergo the test more than once to get an accurate reading.

While a blood sugar test may provide helpful information, there is controversy over the effectiveness of intensive measures to control heart risks in diabetic patients. Only statins, a type of prescription drug, have been shown consistently to be effective.

Step 3: If preliminary testing turns up signs of heart disease, or if you are experiencing symptoms or are at risk for other reasons, more sophisticated screening tests may be in order.

Cost: An electrocardiogram costs around $50 and a stress test costs about $200. Insurance often covers at least part of the fee.

If your doctor determines you are at risk of heart disease or you have a family history of heart disease, you may need to consider an electrocardiogram, or E.K.G., or an exercise stress test.

In an E.K.G., electrodes are attached to your chest, limbs and abdomen to ascertain your heart rate and its pattern, as well as the size and thickness of the heart walls. The electrodes can detect electrical signals of the heart through the skin, which are transcribed onto a graph. You can get results immediately.

A stress test measures the heart’s ability to function while exercising, usually while walking on a treadmill. Some signs of heart disease aren’t visible when your heart is at rest. During exercise you need more blood and oxygen; if your arteries are narrowed, it will be evident during the test.

Step 4: If evidence of heart disease is present, consider coronary angiography.

Cost: Just under $5,000, depending on where you live and your health care provider. At least part of the cost should be covered by insurance.

If the results of an E.K.G. or stress test are worrisome, or if you are having symptoms of heart disease, doctors may prescribe coronary angiography. In some cases, it may be warranted without a stress test first if the patient has a condition that could make the stress test too risky.

During the test, a flexible tube is threaded from the groin into the coronary arteries. A dye is also injected into the bloodstream, so that any blockages in the arteries can be detected on an X-ray. Physicians look for blood vessels that are 50 percent or more blocked.

Avoid: Some sophisticated, expensive heart disease screening tests may pose risks to the patient and may not be effective. For example, patients who receive CT angiography — in which multiple CT scans are used to produce a three-dimensional image of the heart — are exposed to amounts of radiation.

According to a study published last month in The Archives of Internal Medicine, patients at low risk of heart disease who got this test were more likely to be treated aggressively with invasive and potentially risky procedures, but in the end were not less likely to have a heart attack or other coronary problem. For more information on screening tools, visit Consumer Reports Health (consumerreportshealth.org) or the American Heart Association (heart.org).

© 2011 The New York Times Company