Physicians sometimes order cardiac stress tests for symptomless patients out of an abundance of caution, but a University of Florida study found this practice rarely reveals hidden heart issues.
The researchers found few patients, if any, who do not display symptoms of cardiac distress benefited from undergoing stress tests that look for cardiac problems. Their observational study, published online in the Journal of Nuclear Cardiology, relates to a campaign called “Choosing Wisely,” organized by the American Board of Internal Medicine Foundation (a credentialing agency for doctors) and Consumer Reports. The campaign aims to reduce the overuse of tests and procedures.
“Some physicians are more aggressive about and more likely to give these tests in people they are concerned for, or in patients who have risk factors for heart disease,” said David Winchester, M.D., a professor of medicine in the UF College of Medicine and the study’s lead author. “Our study was to show to the medical community that these tests not only have been thought to be unnecessary based on what the professional society is saying, but also in that we don’t see any value in them for the patient.”
This kind of stress test, called myocardial perfusion imaging, is ordered for patients who do not have the appropriate cardiac symptoms about 10 to 15 percent of the time at the Veterans Affairs hospital they studied, Winchester said. Nationally, the rate is 7 to 44 percent, Winchester said.
Winchester found that out of a group of 521 men and women aged approximately 63, 53 who did not display symptoms of cardiac problems were given stress tests. Of these men, only one had heart disease issues, Winchester said.
“In our study, almost nobody had medical interventions such as cardiac catheterization testing done as a result of the inappropriate test,” said Winchester, who is also a staff cardiologist at the Malcom Randall Veterans Affairs Medical Center in Gainesville.
Rebecca Beyth, M.D., M.Sc., an associate professor of medicine within the UF division of general internal medicine who also has a VA appointment, is a co-author of the paper.
“As a general internist, I am hoping that people really think about why it is they are ordering a particular test,” Beyth said.
The test uses small amounts of radiation to trace how the heart is working. The patient receives a radioactive tracer intravenously, then sits in a camera that can detect the photons given off by the tracer. The heart takes up the tracer, and, using the camera, physicians can examine which parts of the heart the tracer did not pass through, which could indicate blockages. The patient performs the test both at rest and after walking on a treadmill or being given a medication that simulates physical activity.
“It’s a very small amount of radiation, but enough that I would not want to perform the test indiscriminately,” Winchester said. “If it’s something the patient needs and can benefit from, it’s a reasonable amount of radiation to expose them to.”
Beyth noted the cost of unnecessary testing. The myocardial perfusion imaging test is a half-day procedure that costs patients between $500 and $1,000 out of pocket.
“If we’re using resources on people who don’t need these resources, maybe we can spend those resources better elsewhere, such as in preventing heart disease,” Beyth said.
The researchers next hope to reduce overuse of testing through the education of both doctors and patients.