It seems like a no brainer. Cardiovascular screening is the #1 killer in the world so broad screening of the general population must be a good idea, right? Wrong, says the consumer group Public Citizen, at least when such screening is performed indiscriminately. Somewhat surprisingly, Public Citizen, which is often held at arm’s length by mainstream medicine, gained some support for its position from a major cardiology organization.
In its statement Public Citizen urged 20 hospitals to sever their involvement in a mobile cardiovascular screening program. The HealthFair Cardiovascular Screening Packages are unethical, mislead consumers, and do more harm than good, said Public Citizen.
In a blog post, the president of the American College of Cardiology. Patrick O’Gara, said that “the questions raised about screening have some merit…. we do not recommend broad and untargeted screening.”
The program, says Public Citizen, “peddles inexpensive cardiovascular disease screening packages to people living near the hospitals and institutions without identifying who has relevant risk factors that would make each of the screening tests medically appropriate. HealthFair’s basic cardiovascular screening packages include six tests that, among other things, take pictures of the heart, measure its electrical activity and look for blockages in arteries.”
“The promotions rely on fearmongering and erroneously suggest that for most adults in the general population, these screening tests are useful in the prevention of several potentially life-threatening cardiovascular illnesses – including heart attacks, strokes and ruptured abdominal aortic aneurysms – and make them sound like an appealing bargain,” according to Public Citizen. Among the harms cited by Public Citizen are false-positive results or the discovery of inconsequential abnormalities. ”Both circumstances can lead to additional unnecessary and risky tests and treatments that will harm some people, cause unfounded anxiety, and cost patients and insurance companies.”
Here is O’Gara’s statement about the issues raised by Public Citizen:
“The questions raised about screening have some merit. The American College of Cardiology and American Heart Association have joint guidelines that offer recommendations to guide physicians in making decisions with individual patients about their risk for heart attack and stroke. Other than assessing blood pressure and serum cholesterol, being attentive to diabetes and promoting a healthy weight with regular exercise, we do not recommend broad and untargeted screening. Decisions about the need for additional testing should be based on each patient’s circumstances.
“The American College of Cardiology participates in the Choosing Wisely campaign, which encourages physicians and patients to discuss the costs and benefits of often overused tests and procedures.”
Ethan Weiss, a cardiologist at the University of California at San Francisco, sent the following explanation for the counter-intuitive perspective on the dangers of screening:
Conceptually, people (including many doctors) believe that we should do everything we can to discover occult disease like heart disease. The assumption is that if we look hard enough, we can find disease and intervene to change the outcome in a positive way. People may ask, “What’s the harm?” However, for cardiology at least, there is no evidence to support this assumption outside of screening for hypertension, lipid abnormalities and diabetes. This situation is worsened when options such as executive physicals are offered, which harden the perception that there must be some health benefit, but you just need money to access it. Again, sadly, this is not supported by evidence.
There can be serious consequences to false positive results. Usually the harm is limited to unnecessary anxiety caused by false-positive tests, but there are also costs (many of these tests are not reimbursed) and the rare cases where false positives result in more tests that lead to complications and very serious medical consequences.
Here is another anecdote: I once had a symptomatic patient with well-managed risk factors who insisted on having a nuclear stress test annually. It had been something started by a colleague of mine who had seen him before me — a very senior and respected doctor — and it was hard for me as a young doctor to overcome the perception that I did not know what I was talking about.
I kept doing the stress tests for a few years, but all the while I tried to convince him it was a mistake. I finally resorted to telling him that I was concerned about all the radiation he was getting. He continued to insist on the tests because he believed (firmly) that this was helping him and could not harm him.
One summer, I got an urgent call from him from the U.S./Canada border where he was being detained —he had set off the Geiger counter crossing the border a few days after his stress test. He was shaken. I reassured him and convinced the border patrol that he was not a terrorist. The next time he came to see me, he agreed to stop having stress tests and has not had one since.
I do believe that we can and will eventually improve our prediction tools. Right now blood pressure, lipids, and diabetes are the only validated — and thus, recommended — things to screen. This does not mean that we don¹t talk about other factors such as
weight, body composition, nutrition, and exercise with our patients. The truth is that the evidence basis for these factors are pretty flimsy too, but we make the assumption that it can’t hurt, and I try to remind patients where we have strong evidence and where we do not.
The bottom line for me is to be honest with patients about what prediction and prevention tools we have and what the evidence basis is for each of them. Going forward, we need to work on more robust and careful studies from which we can learn how to better identify at-risk individuals and also validate whether the new tools do what they should. Finally, we should work to show that the information we learn from these tools can help improve clinical outcomes.