Echoing the appropriate use criteria: the role of echocardiography for cardiovascular risk assessment of the asymptomatic individual.

Cardiovascular disease (CVD) is the leading cause of death in developedcountries, andmanywhodie suddenlyofCVDhave no previous symptoms.1 Therefore, there is great interest in identifying at-risk individuals so that appropriate preventive measurescanbe implemented.All asymptomaticadults should undergo global risk assessment. For carefully selected individuals deemed at intermediate risk, noninvasive imagingmethods formeasuring coronary artery calcium level or carotid intima–media thickness are additional tools for risk stratification,with class IIa indications (benefits exceed risks) in the 2010 American College of Cardiology Foundation/ AmericanHeart Association guidelines.2 Althoughpredictive of risk above traditional risk factor assessment, it remains untested whether risk assessment with these or other tests directly produces changes in management that improve outcomes. Transthoracic echocardiography is a widely used tool for the diagnosis and management of CVD. Most echocardiograms are ordered by primary care physicians rather than cardiologists.3 Population-based investigationsof asymptomatic individuals screenedbyechocardiographyhave foundthat incidental findings, suchas asymptomatic left ventricular (LV) dysfunction and LV hypertrophy, can predict cardiovascular and all-cause mortality independent of blood pressure and other risk factors.2 TheAmericanCollege of CardiologyFoundation/AmericanHeartAssociationguidelinesgive restingechocardiography screening a class IIb indication (benefit somewhat better than risk) for thedetectionof LVhypertrophy and LVdysfunction forasymptomaticadultswithhypertensionbut aclass III (nobenefit) for thosewithouthypertension.2Todate, no studies have examined whether a patient’s knowledge of his or her echocardiogram results, including LV hypertrophy, improves adherence topreventivemeasures and lifestyle recommendations. Among Medicare-recipient patients, there has been increaseduseof noninvasive and invasive cardiac services from 1993 to2011,notexplainedbychanges inCVDprevalence.4Cardiovascular diseasemortality has also declined between 1997 and 2007 by 26%, although the burden of CVD remains high.1 In response to the growinguse of echocardiography (about an 8% annual increase3), the American Society of Echocardiography in 2011updated their appropriateuse criteria (AUC) consensus statement.5 Since then, AUC have been a focus for accreditation societies and payers alike to improve quality and curtail medical expenses. The AUC for echocardiography are mostly basedon expert consensus andobservational data because randomized clinical trial data testing the usefulness of echocardiography-guided compared with nonguided management were unavailable for most indications. Hypertrophic cardiomyopathy is present in 1 in 500of the general population and is themost frequent cause of sudden cardiacdeath inyoungpeople (including trainedathletes). After the introductionofapreparticipationathletic screeningprogram in Italy (first with physical examination and an electrocardiogram,and thenechocardiography ifneeded), adeclining incidenceof suddencardiacdeath inathleteswasnoted.6However, the AUC by the American Society of Echocardiography do not endorse routine echocardiography screening for athletes participating in competitive sports who have normal results on a cardiovascular examination.5 The role for cardiovascular screening of presumably healthy athletes remains controversial givengenerally lowratesof suddencardiacdeath in this population. In this issue of JAMA Internal Medicine, Lindekleiv et al7 present results from the Tromso cohort, a population-based study conducted in Norway. During their fourth survey, participants were randomly allocated to 1 of 2 types of examination. This design essentially randomized unselected, generallymiddle-aged, individuals toastrategyofechocardiography screening vs no echocardiography. This was not designed as a clinical trial, nor was the usefulness of echocardiography screening for mortality their a priori hypothesis. Of 3272 participants allocated to echocardiography, 362had findings that met the referral criteria for cardiology, and 290 (8.9%) were newly evaluated as a result of screening. Significant incidental findingsnoted includedmyxoma,LVdysfunction,wallmotion abnormality, andvalvular disease. Despite cardiology referral for these diagnoses,mortality during 15 follow-upyears was unchanged between the screened and nonscreened groups. Therewasno reduction in incidentmyocardial infarction or stroke, but other morbidity outcomes, such as freedomfromcardiac surgery (perhaps for valvular disease),were not examined. During the Tromso Study fourth examination, 6727 individuals underwent carotid screening.8 It is unclear howmany of these individuals also had echocardiography. If these individualswere in thenoechocardiogramtreatment arm, the authors may be comparing echocardiography with other types Related article page 1592 Research Original Investigation Echocardiographic Screening and Long-term Survival