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Prevention Magazine Pushes Non-Evidence-Based Heart Screening

Prev. mag pullout.jpgThe February issue of Prevention magazine has an article entitled “Surprising Faces of Heart Attack” profiling “three women (who) didn’t think they were at high risk. Their stories are proof that you could be in danger without even knowing it.” No, their stories are not proof of that.

The story is about three women in their 40s. The story varyingly states that the three should have had the following screening tests:

— Advanced cholesterol test, carotid intimal medial thickness test ( CIMT)
— Advanced cholesterol test and stress echocardiography
— Cardiac calcium scoring and CIMT

 There’s an accompanying piece: “7 Tests You’re Not Having That Could Save Your Life.”

Harry Demonaco photo.jpgI asked one of our medical editors, Harold Demonaco, director of the Innovation Support Center at the Massachusetts General Hospital, to review the two pieces. As his day-job title suggests, he deals with review of the evidence for new and emerging healthcare technologies. He wrote: 

The section “7 Tests you are not having that could save your life” states: “If you have not had these cutting edge screenings, put this magazine down and call your doctor. Now.”

Wow. While much of the information is correct, it is the context that is disturbing. Suggesting that these tests are essential in everyone is a bit over the top. Some of the information provided for each test is basically correct. However in some cases the recommendations go well beyond national guidelines.

The major issue here is the tacit assumption that tests are infallible, without any downsides and are always a good thing. That is simply not the case. So who should get these tests?

Here’s what national guidelines suggest:

1. Cardiac calcium scoring. The most recent recommendations in 2007 states:

“….it may be reasonable to consider the use of Coronary Artery Calcium scoring measurement in asymptomatic patients with intermediate coronary heart disease…” Intermediate risk implies a 10 to 20 percent risk of a coronary event in the next 10 years.

“The committee does not recommend use of Coronary Artery Calcium measurement in people with low risk (below a 10 percent risk of a coronary event in the next 10 years. This patient group is similar to the ‘population screening’ scenario, and the committee does not recommend screening of the general population using CAC measurement.”

A far cry from what is being suggested in the article.

2. Carotid intimal medial thickness. The article suggest the test is needed if you are over age 40 or if you are under 40 and a close relative had a heart attack or stroke before age 55. Here’s what the U.S. Preventive Services Task Force said in 2009:

“Carotid intima-media thickness (CIMT) measurement is a noninvasive test that serves as a surrogate marker for coronary atherosclerosis. There is a correlation between CIMT and traditional coronary risk factors. The clinical utility of measuring IMT for the purpose of predicting risk of coronary or cerebral events has not been established. It is not evident from the literature that CIMT is able to improve on risk prediction above what is provided by utilization of traditional risk factors or the effect of these measurements on patient outcomes.”

3. Advanced lipid profile and lipoprotein test. The article notes: “Get Them If: You have a family history of heart disease.”

But, the 2010 guidelines from the American College of Cardiology and the American Heart Association suggests that lipid parameters beyond standard fasting lipid profile are not recommended in asymptomatic adults.

4. DNA detection

Anyone over age 40 should have genetic testing according to the article. A published meta analysis from the Journal of the American College of Cardiology found, “ significant relationship between development of clinical coronary artery disease and the gene variant…” Hardly an endorsement for use of the test in anyone over the age of 40.

The article is basically within standard guidelines with regard to testing with A1C and stress echocardiography.

Surprising faces of heart attack

Each of the women’s stories represents a teaching moment that is lost. The histories are incomplete and little can be said other than generalities. Having said that, each story is interesting in what is said. One woman is said to have hypersomnia requiring her to have 10 to 12 hours sleep each night. Hypersomnia is a condition that results in excessive sleepiness during the day. There is also a suggestion that five hours of sleep nightly increases risk of a cardiac event. That is perhaps true if the person is sleep deprived. It is probably not true if, like many people, five hours sleep is sufficient. Suggesting that all of us need 10 to 12 hours sleep is not supported by any literature.

Another woman is described as a 47-year-old woman who at the time of her heart attack was morbidly obese (her height of 5 ft 4 inches and a weight of 245 pounds gives her a body mass index of 42, well into a range defined as morbidly obese.) This single element in her history places her in a high risk category.

Ms. Younger had borderline obesity when she had her heart attack. Perhaps the tests suggested are appropriate but other more mainstream tests should be done prior to these high tech options according to standards of care. Rather than focusing on high tech and in some case rather controversial tests as being necessary, where is the recommendation on primary care, an annual physical and most importantly on lifestyle modification?

For a magazine named “Prevention” there seems to be a good deal of emphasis on high-tech testing and not on preventive medicine.

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

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One Response to “Prevention Magazine Pushes Non-Evidence-Based Heart Screening”

  1. It puzzles me why Doctor Harold Demonaco refers to “The most recent recommendations in 2007 state” from 2007 while he can use the recent “2010 ACCF/AHA Guideline for CV Risk in Asymptomatic Adults”.
    About Calcium Scoring here’s what they say:
    20. Recommendations for Calcium Scoring Methods
    Class IIa
    1. Measurement of CAC is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk (10% to 20% 10-year risk).[52,53](Level of Evidence: B)
    Class IIb
    1. Measurement of CAC may be reasonable for cardiovascular risk assessment in persons at low to intermediate risk (6% to 10% 10-year risk).[53–55](Level of Evidence: B)
    Class III: No Benefit
    1. Persons at low risk (<6% 10-year risk) should not undergo CAC measurement for cardiovascular risk assessment.[52,53,56](Level of Evidence: B)
    J Am Coll Cardiol. 2010;56(25):2182-2199. © 2010 Elsevier Science, Inc.

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