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Some screening for heart disease could be unnecessary
A recent survey conducted by Consumer Reports asked 8,056 of their members between the ages of 40 and 60 if they had been recently screened for risk factors for heart disease and which tests had been done.
All of the subjects were at low risk of developing heart problems. Over 80 percent had their cholesterol levels measured and their blood pressure checked, but over 60 percent also had tests not recommended for healthy individuals, including: an EKG (50 percent); an exercise stress test (21 percent); or carotid artery ultrasound (7 percent).
Over 87 percent having the tests believed it was better to have a scare that turned out to be nothing than not being testing at all.
Dr. John Santa, an expert in health screening and director of Consumer Report's Health Rating Center, noted that these tests are not particularly accurate for low or normal risk individuals and that false positives are not uncommon. This can lead to more tests including coronary angiograms. CT angiography is not without risk. Unnecessary testing leads to treatments, including medications, that be of no value and angioplasty that may be of no proven benefit.
Preventing heart disease must focus on diet, exercise, stress management, maintaining an ideal weight and a normal cholesterol and blood pressure. Between age 20 and 50, screening for elevated cholesterol and diabetes should be done every five years and blood pressure measurements obtained at least annually. After age 50, the tests may be needed more frequently.
But what about more extensive testing?
This should be reserved for those who have symptoms suggesting heart disease (chest pain or shortness of breath) and in certain circumstances for healthy individuals who are at high risk of heart disease. Everyone should know their risk of developing heart disease in the coming years.
Today, numerous screening tools are available, that can accurately tell you whether you are at low, moderate or high risk of having or developing heart disease. Most are based on information obtained from the Framingham Study that, for the past 60 years, has prospectively followed almost the entire population of the city of Framingham, Mass., to determine the prevalence and severity of heart disease.
Many are available on the internet. Merely add easily available information and your risk level will be immediately determined. An excellent heart attack assessment risk calculator is available on the American Heart Association website — www.heart.org.
The most important factors determine your risk of having a heart attack include: age, being a male or post menopausal woman, a strong family history of heart attacks at a young age, smoking, a total cholesterol above 220, a bad or LDL cholesterol above 150 and a ratio of the LDL divided by the HDL or good cholesterol above 5.
Being diagnosed with high blood pressure (a top or systolic blood pressure above 135 or a bottom or diastolic above 90), having diabetes or prediabetes and being obese are important risk factors as well. Finally having evidence of inflammation in the body as measured by an elevated C reactive protein is associated with a higher risk of coronary artery disease.
For an individual deemed to be at very high risk of heart attack, an EKG and a stress test may be a consideration if deemed necessary by a physician. If an abnormality is noted, referral to a cardiologist is warranted to determine the extent and severity of coronary artery disease and to determine if further interventions are needed.
It is these individuals in whom severe narrowing of a specific coronary artery may be identified that indicates an increased risk of death from a heart attack. This is referred to as isolated left main disease, an artery also referred to as the widow maker. Usually an angioplasty or open heart surgery is recommended.
The need for an invasive intervention in high-risk asymptomatic individuals is fortunately rare. However medical management to reduce the risk of further development and progression of coronary artery disease becomes critically important. This involves compulsive control of high blood pressure, treatment of diabetes, lower cholesterol and prescribing medications know to reduce the risk of heart attacks and strokes (beta blockers and ACE inhibitors).
Doing too much testing is never a good idea. Appropriate management and screening for heart disease depending on measurable risk factors will assure the best possible care to those who need it.
Dr. David Lipschitz is the medical director for the Mruk Family Education Center on Aging and the Fairlamb Senior Health Clinic. Contact him at firstname.lastname@example.org.