Should the resting electrocardiogram be ordered as a routine risk assessment test in healthy asymptomatic adults?

THE ROUTINE OR SCREENING ELECTROCARDIOGRAM (ECG) appears to be a common office procedure, even in the current era of cost-conscious health care. In 1989, Sox et al summarized the existing evidence concerning use of the resting ECG as a screening test. The authors concluded that additional study was needed, including a randomized study of the resting ECG as a screening test to provide a measure of its health effects, and called especially for studies in patients older than 65 years, because the prevalence of coronary artery disease in asymptomatic persons increases with age. The authors stated that “the final word on the value of a screening ECG has yet to be said, but we feel that the arguments for doing it as a routine practice are not compelling at this time. ” What has changed since 1989 in regard to the use of this commonly conducted office procedure? Specifically, is there additional evidence about the risk associated with resting ECG abnormalities? Is there new evidence that the resting ECG can add incrementally to risk measures that are already commonly assessed such as cholesterol level, blood pressure measurement, and cigarette smoking? Of critical importance, is there now clinical trial evidence that supports the use of the resting ECG to improve patient outcomes, not just improvement of risk assessment? If any of these questions remains unanswered, what would be the best way to move this field forward in the current era emphasizing comparative effectiveness research and pragmatic clinical trials? During the last 23 years, many additional studies have shown that the resting ECG can identify abnormalities that are associated with modestly increased cardiovascular disease event risks compared with standard (traditional) risk factors. Chou et al conducted a systematic and comprehensive review of the evidence for resting ECG in asymptomatic adults under auspices of the US Preventive Services Task Force. The authors found 27 suitable prospective cohort studies of resting ECG, reported in 28 publications, and nearly all of these prospective studies were published since the 1989 report by Sox et al. These data represented 173 710 asymptomatic individuals. Duration of follow-up ranged between 3 and 56 years. Ten studies were rated good quality and the rest were rated fair quality, often due to lack of information on handling of participants with uninterpretable ECG results or loss to follow-up. The pooled adjusted hazard ratio (HR) was 1.9 (95% CI, 1.4-2.5) for persons with resting ST-segment abnormalities (5 studies), 1.6 (95% CI, 1.3-1.8) for those with T-wave abnormalities (6 studies), and 1.9 (95% CI, 1.6-2.4) for those with either STsegment or T-wave abnormalities (7 studies). Other studies evaluated predictive information derived from left ventricular hypertrophy, left-axis deviation, and bundle branch block on resting ECG; each of these was associated with a similar risk level (HRs of approximately 1.6-1.9) for subsequent cardiovascular events. In this issue of JAMA, Auer et al report data from 2192 white and black men and women aged 70 to 79 years, without known cardiovascular disease, examined for the potential additive predictive role of major and minor ECG abnormalities above and beyond traditional risk factors for coronary heart disease events. More than 20% of the participants had at least 1 major or minor ECG abnormality. During a follow-up of approximately 8 years, both major and minor ECG abnormalities were associated with increased risk of coronary heart disease after adjustment for traditional risk factors. Adjusted HRs were 1.35 (95% CI, 1.02-1.81) for minor abnormalities and 1.51 (95% CI, 1.201.90) for major abnormalities. Previously reported HRs in predominantly younger populations are similar to the results of Auer et al. Although the results reported by Auer et al add new information pertinent to older adults and now include black as well as white individuals, the study results are consistent with the prior extensive literature on risks associated with abnormalities on the resting ECG in asymptomatic persons.