From Our 2012 Archives
Task Force Updates EKG Recommendations
Low-Risk People Without Symptoms Do Not Need EKG, Group Says
By Kathleen Doheny
Reviewed by Louise Chang, MD
July 30, 2012 -- If you're at low risk for heart disease and don't have symptoms such as chest pains, you do not need a routine electrocardiogram (EKG or ECG), according to updated guidelines from the U.S. Preventive Services Task Force.
If you are at intermediate or high risk but don't have symptoms, there is not enough evidence to say one way or the other whether an EKG will help predict heart disease, says Joy Melnikow, MD, PhD, a member of the task force.
The updated recommendations focus on a specific group, Melnikow says. "This recommendation addresses people without any symptoms of heart disease who are coming to their doctor to find out what they need to do to be healthier."
The task force is an independent panel of experts that considers multiple sources of evidence and makes recommendations about preventive services and tests.
The task force focused on just the EKG, which checks for problems with the heart's electrical activity. It is often done to find the cause of symptoms such as chest pain. An EKG can be a resting EKG or an exercise EKG, also called a treadmill test.
The task force looked at evidence gathered since 2004. The updated EKG recommendations echo the previous ones.
Other organizations differ in their recommendations.
The task force guidelines are published in the Annals of Internal Medicine.
EKG Recommendations in Detail
The panel asked one question, says Melnikow, professor of family and community medicine at the University of California, Davis. "Once [a person is] evaluated for other risk factors for heart disease -- such as smoking, high cholesterol, sedentary lifestyle, high blood pressure -- does it help to add a screening test with either a resting ECG or an exercise ECG?"
"Our answer is, the net benefit of that is zero or possibly slight harm in low-risk people," Melnikow says.
Among the possible harms are false-positive EKGs. Those could lead to unnecessary procedures such as angioplasty, she says.
For intermediate- and high-risk adults, the evidence was not sufficient to make a recommendation, the task force says.
More About Risk Categories
Your doctor can estimate your risk by using your total cholesterol, HDL or "good" cholesterol, and blood pressure numbers along with information such as age, gender, and smoking history.
"You are at low risk if you have less than a 10% risk of heart attack or death from coronary heart disease in the next 10 years," Melnikow says.
Those with a 10% to 20% risk of heart disease in the next 10 years are at intermediate risk. A 10-year risk greater than 20% is high risk.
Scope of the EKG Recommendations
The task force considers evidence only. The recommendations provide doctors the best evidence for a test or service.
Doctors then use their clinical judgment when deciding which tests to do.
The panel doesn't consider cost. But for the record, costs vary. A resting EKG is about $50. In 2011, Medicare reimbursed $92 for a treadmill test.
New EKG Recommendations: Perspectives
The guidelines clarify that for a low-risk person without symptoms, getting an EKG doesn't add anything, says Ravi Dave, MD, attending cardiologist at UCLA Medical Center, Santa Monica.
He reviewed the updated guidelines for WebMD.
"For intermediate to high-risk, it leaves it up to doctors," he says.
"I think doctors [sometimes] do an EKG to avoid missing a major abnormality," Dave says. "What we can get from this study is, the evidence suggests there is no need to do a routine EKG on a low-risk person without symptoms."
Suzanne Steinbaum, DO, director of women and heart disease at Lenox Hill Hospital, New York, doesn't agree totally with the new EKG recommendations.
For those who are low risk and without symptoms of heart disease, she agrees that repeated EKGs done routinely over the years are not necessary.
However, she says, "I think everyone needs an EKG at some point in their life when they are healthy."
This EKG can then serve as a comparison later, if symptoms occur and an EKG is ordered, says Steinbaum.
Routine EKGs: Other Guidelines
The American Academy of Family Physicians does not recommend routine EKGs as part of a periodic health exam in adults without symptoms.
However, the American College of Cardiology Foundation and the American Heart Association state that a resting EKG is ''reasonable" to assess risk in an adult with no symptoms who has high blood pressure or diabetes.
It can be considered in others without symptoms who don't have diabetes or high blood pressure.
An exercise EKG could be considered in those at intermediate risk without symptoms, including those just beginning to exercise vigorously, according to the same guidelines.
Heart Health: Other Steps
Lifestyle changes can improve heart health, Melnikow says.
"We know very clearly people can lower their risk of heart disease by quitting smoking, lowering their cholesterol, lowering their blood pressure if it is high, and being physically active," she says.
SOURCES: Joy Melnikow, MD, MPH, professor of family and community medicine; director, Center for Healthcare Policy and Research, University of California, Davis. Annals of Internal Medicine, published online July 31, 2012. Ravi Dave, attending cardiologist, UCLA Medical Center, Santa Monica, Calif.; professor of medicine, University of California Los Angeles David Geffen School of Medicine. Suzanne Steinbaum, DO, director, Women and Heart Disease, Lenox Hill Hospital, New York; national spokeswoman, Go Red for Women campaign, American Heart Association.
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