What are the recommendations for asymptomatic screening for coronary artery disease (CAD)?

From the Guidelines

Routine screening for asymptomatic heart disease is not recommended for the general population without risk factors. Instead, a targeted approach is advised based on individual risk assessment. Adults should undergo cardiovascular risk assessment starting at age 40, or earlier if they have risk factors such as family history of premature heart disease, diabetes, hypertension, smoking, obesity, or high cholesterol. This assessment typically includes blood pressure measurement, lipid panel (total cholesterol, LDL, HDL, triglycerides), blood glucose testing, and calculation of a 10-year cardiovascular risk score. For those at intermediate or high risk, additional testing may be appropriate, including electrocardiogram (ECG), stress testing, or coronary calcium scoring. Specific high-risk groups, such as those with diabetes over age 40 or strong family history of premature coronary disease, may benefit from more intensive screening. The rationale for selective rather than universal screening is that false positives in low-risk individuals can lead to unnecessary anxiety, additional testing, and interventions without clear benefit. Instead, focusing on modifiable risk factors through lifestyle changes (regular exercise, healthy diet, smoking cessation) and appropriate medical therapy when indicated provides greater benefit for most people. According to the most recent and highest quality study, the USPSTF concludes that evidence is lacking and the balance of benefits and harms of screening for CHD with exercise or resting ECG in asymptomatic adults at intermediate or high risk for CHD events cannot be determined 1. Additionally, a study published in Diabetes Care in 2021 found that the screening of asymptomatic patients with high ASCVD risk is not recommended, in part because these high-risk patients should already be receiving intensive medical therapy—an approach that provides similar benefit as invasive revascularization 1.

Some key points to consider when deciding on screening for asymptomatic heart disease include:

• The potential benefits and harms of screening, including the risk of false positives and unnecessary interventions
• The individual's risk factors and overall risk profile
• The availability and accuracy of screening tests, such as ECG and coronary calcium scoring
• The potential impact of screening on patient outcomes and quality of life. As noted in a study published in the Journal of the American College of Cardiology in 2011, patients with subclinical atherosclerosis identified by accurate imaging tests can be expected to benefit from preventive treatment because they are at elevated risk for an event 1.

Overall, a targeted and individualized approach to screening for asymptomatic heart disease is recommended, taking into account the latest evidence and guidelines from reputable sources, such as the USPSTF and the American College of Cardiology.

From the Research

Screening Strategies for Asymptomatic Adults

• The American College of Physicians (ACP) recommends against screening for asymptomatic patients who are at low risk for coronary heart disease (CHD) 2.
• Instead, the ACP recommends a focus on proven strategies, such as treatment of hypertension and hypercholesterolemia, to reduce risk in appropriately selected asymptomatic persons 2.
• Global risk assessment and screening strategies, including blood pressure, lipids, C-reactive protein, homocysteine, coronary artery calcium score, carotid intima-media thickness, ultrasound of the abdominal aorta, and electrocardiography, can be used to assess cardiovascular risk in asymptomatic adults 3.

Risk Assessment and Prediction

• Several algorithms, such as the Framingham Risk Score, Adult Treatment Panel III, SCORE project, Reynolds Risk Score, ASSIGN, and QRISK, can be used to assess cardiovascular risk in individual patients 4.
• Lipoprotein cholesterol levels, triglycerides, lipoprotein(a), apolipoproteins A-I and B, and HDL density subfractions can be used to predict coronary heart disease risk 5.
• Abnormalities on resting or exercise electrocardiography, such as ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation, are associated with increased risk of cardiovascular events 6.

Recommendations for Screening

• Routine testing for cardiovascular risk factors and risk score assessment can help identify asymptomatic adults who are at high risk for cardiovascular disease 4.
• Health care providers should discuss global cardiovascular risk and lifetime cardiovascular risk score assessment with each patient to better explain each patient's future risk 4.
• The U.S. Preventive Services Task Force found that abnormalities on resting or exercise electrocardiography are associated with an increased risk for subsequent cardiovascular events, but the clinical implications of these findings are unclear 6.