Screening for Coronary Heart Disease: Recommendation Statement Electrocardiographic Minnesota code findings predicting short-term mortality in asymptomatic subjects. The Italian RIFLE Pooling Project (Risk Factors and Life Expectancy). Scintigraphic and electrocardiographic evidence of silent coronary artery disease in asymptomatic hypertension: a case-control study. Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization. Electrocardiographic findings and incident coronary heart disease among participants in the Atherosclerosis Risk in Communities (ARIC) study. Prognostic value of ECG findings for total, cardiovascular disease, and coronary heart disease death in men and women The additional value of routine electrocardiograms in cardiovascular risk management of older people The Social Insurance Institution's coronary heart disease study. Baseline data and 5-year mortality experience. Should everyone with an ejection fraction less than or equal to 30% receive an implantable cardioverter-defibrillator? Not everyone with an ejection fraction < or = 30% should receive an implantable cardioverter-defibrillator. Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death. Multicenter Unsustained Tachycardia Trial Investigators. Detecting Occult Coronary Disease in a High-Risk Asymptomatic Population Electrocardiography and outcome in patients with diabetes mellitus on maintenance hemodialysis. Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients. Maximal exercise test as a predictor of risk for mortality from coronary heart disease in asymptomatic men. Prognostic value of exercise EKG testing in asymptomatic normotensive subjects. A prospective matched study. Symptom-limited exercise testing, ST depressions and long-term coronary heart disease mortality in apparently healthy middle-aged men Major and minor ECG abnormalities in asymptomatic women and risk of cardiovascular events and mortality.
Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends against routine screening with resting electrocardiography ( ECG ) , exercise treadmill test ( ETT ) , or electron-beam computerized tomography ( EBCT ) scanning for coronary calcium for either the presence of severe coronary artery stenosis ( CAS ) or the prediction of coronary heart disease ( CHD ) events in adults at low risk for CHD events . This is a grade D recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found at least fair evidence that ECG or ETT can detect some asymptomatic adults at increased risk for CHD events independent of conventional CHD risk factors ( see Clinical Considerations ) and that ETT can detect severe CAS in a small number of asymptomatic adults . Similar evidence for EBCT is limited . In the absence of evidence that such detection by ECG , ETT , or EBCT among adults at low risk for CHD events ultimately results in improved health outcomes , and because false-positive tests are likely to cause harm , including unnecessary invasive procedures , overtreatment , and labeling , the USPSTF concluded that the potential harms of routine screening for CHD in this population exceed the potential benefits . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 1 . U.S. Preventive Services Task Force Grade s and Recommendations Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence The USPSTF found insufficient evidence to recommend for or against routine screening with ECG , ETT , or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events . This is a grade I recommendation . The USPSTF found inadequate evidence to determine the extent to which the added detection offered by ECG , ETT , or EBCT ( beyond that obtained by ascertainment of conventional CHD risk factors ) ( see Clinical Considerations ) would result in interventions that lead to improved CHD-related health outcomes among adults at increased risk for CHD events . Although there is limited evidence to determine the magnitude of harms from screening this population , harms from false-positive tests ( that is , unnecessary invasive procedures , overtreatment , and labeling ) are likely to occur . As a result , the USPSTF could not determine the balance between benefits and harms of screening this population for CHD . Clinical Considerations Several factors are associated with a higher risk for CHD events ( the major ones are nonfatal myocardial infa rct ion and coronary death ) , including older age , male gender , high blood pressure , smoking , abnormal lipid levels , diabetes , obesity , and sedentary lifestyle . A person 's risk for CHD events can be estimated on the basis of the presence of these factors . Calculators are available to ascertain a person 's risk for a CHD event ; for example , a calculator to estimate a person 's risk for a CHD event in the next 10 years can be accessed at hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof . Although the exact risk factors that constitute each of these categories ( low or increased risk ) have not been established , younger adults ( that is , men<50 years of age and women<60 years of age ) who have no other risk factors for CHD ( < 5 % to 10 % 10-year risk ) are considered to be at low risk . Older adults , or younger adults with one or more risk factors ( > 15 % to 20 % 10-year risk ) , are considered to be at increased risk . Screening with ECG , ETT , and EBCT could potentially reduce CHD events in 2 ways : either by detecting people at high risk for CHD events who could benefit from more aggressive risk factor modification or by detecting people with existing severe CAS whose life could be prolonged by coronary artery bypass grafting ( CABG ) surgery . However , the evidence is inadequate to determine the extent to which people detected through screening in either situation would benefit from either type of intervention . The consequences of false-positive tests may potentially outweigh the benefits of screening . False-positive tests are common among asymptomatic adults , especially women , and may lead to unnecessary diagnostic testing , overtreatment , and labeling . Because the sensitivity of these tests is limited , screening could also result in false-negative results . A negative test does not rule out the presence of severe CAS or a future CHD event . For people in certain occupations , such as pilots and heavy equipment operators ( for whom sudden incapacitation or sudden death may endanger the safety of others ) , considerations other than the health benefit to the individual patient may influence the decision to screen for CHD . Although some exercise programs initially screen asymptomatic participants with ETT , there is not enough evidence to determine the balance of benefits and harms of this practice . Discussion Coronary heart disease is the leading cause of death in the United States ; more than 700000 of the deaths in 2000 were due to heart disease ( 1 ) . The overall costs of CHD and stroke in 2003 are estimated to be greater than $ 350 billion ( 2 ) . Many clinicians ascertain a person 's overall risk for CHD events by screening for cardiac risk factors and incorporating that information into risk prediction equations derived from the Framingham or other cohort studies ( 3 , 4 ) . Asymptomatic adults clearly benefit from risk factor modification proportional to their degree of CHD risk ( that is , more intensive risk factor modification for people at higher risk ) ( 5 ) . Since those at high risk for CHD may already be receiving interventions to maximally reduce their risk for CHD events , screening may potentially be of greatest benefit to those presumed to be at intermediate risk for CHD who could be reclassified as being at high risk ( and thus treated more aggressively ) after additional testing . In addition to risk factor reduction , persons with symptoms of CHD who have severe CAS ( defined as either triple-vessel or left main coronary artery atherosclerotic disease with poor left ventricular function ) clearly benefit from CABG or percutaneous transluminal coronary angioplasty ( 6 - 8 ) . Among the asymptomatic population , those at higher risk for CHD events have a higher prevalence of severe CAS ; thus , the yield of screening is expected to be greater in this population . However , it is uncertain whether this increased yield increases the detection of people with severe CAS to an important degree and whether invasive revascularization procedures would benefit those who are asymptomatic as much as those who have symptoms of CAS . The USPSTF review ed the evidence as to whether supplementing the conventional CHD risk ascertainment strategy with additional screening using ECG , ETT , or EBCT , or using these 3 tests to identify people with severe CAS earlier , would lead to improved health outcomes in asymptomatic persons . The USPSTF found no r and omized , controlled trials with health outcomes that examined the extent to which  ECG , ETT , or EBCT scanning for coronary calcium provided additional prognostic information beyond the currently used risk factor calculations . The Task Force further found that the 3 screening testsECG , ETT , and EBCThave poor to fair accuracy in predicting CHD events . Systematic review s have reported that the sensitivity of resting ECG abnormalities for CHD events is low ( 3 , 9 ) . The prevalence of the most common ECG abnormalities ( Q waves , left ventricular hypertrophy , bundle-branch blocks , and ST-segment depression ) ranges from 1 % to 10 % ( 3 ) . Only a few studies have examined ECG abnormalities in the black population . Although major ECG abnormalities may be more prevalent in black men than in white men , these abnormalities may not confer the same risk for CHD death in black men ( relative risk , 1.95 [ 95 % CI , 0.93 to 4.11 ] ) as in white men ( relative risk , 2.72 [ CI , 1.47 to 5.04 ] ) ( 10 ) . The sensitivity of ETT  for the prediction of CHD events 3 to 12 years in the future ranges from 40 % to 62 % ; the positive predictive value ( PPV ) ranges from 6 % to 48 % . The higher sensitivity of ETT  reported in older studies may not be accurate because of the possibility of spectrum bias ( 11 , 12 ) . The prevalence of an abnormal ETT ( ST-segment depression 1 mm ) reportedly ranges from 5 % to 25 % ( 3 ) . The yield of ETT  in detecting severe CAS in asymptomatic middle-aged men is estimated to be 0.5 % ( 3 , 13 ) . The PPV for future CHD in recent cohort studies ( most of them conducted with asymptomatic men ) is low ( range , 6 % to 48 % ) ( 3 ) . Adding nuclear perfusion to ECG analysis may increase sensitivity somewhat ; however , the low PPV of ETT is due mainly to the low prevalence of CHD in asymptomatic persons and can not be corrected simply by improving test accuracy . For patients with symptoms of CHD , EBCT has a sensitivity of 80 % and a specificity of 40 % for detecting angiographically demonstrated CAS ( 14 ) ; similar data for those who have no symptoms are lacking . A systematic review reported that higher calcium scores on EBCT were associated with higher risk for CHD events ( 3 ) . This review concluded that EBCT may have a role in better defining risk for CHD events in those who have been identified as being at intermediate risk based on traditional risk factors , but no study has examined the effect of EBCT data on clinical decision making ( 3 ) . Potential harms of screening asymptomatic patients for CHD include unnecessary invasive testing ( for example , coronary angiography ) and labeling of those who have had false-positive test results . In low-risk asymptomatic population s , most positive ECG test results occur in those who will not have a CHD event in the next 5 to 10 years ( 3 ) . One study reported that 71 % of those without symptoms who had an abnormal ETT had no angiographically demonstrable CAS ( 15 ) . While the yield of screening is low in those at low risk for CHD , the potential for Aim of the study was to analyze the predictive power on short term mortality of electrocardiographic findings in asymptomatic subjects belonging to sample s of the general population . In the Italian RIFLE Pooling Project ( Risk Factors and Life Expectancy ) 12 180 men and 10 373 women aged 30 to 69 years had a resting electrocardiogram ( ECG ) recorded at baseline examination . All of them were free from clinical ly symptomatic heart disease and represented 23 cohorts spread all over Italy .  ECGs were read by the Minnesota Code using 5 large categories of abnormalities , i.e. Q-QS abnormalities , ST-T abnormalities , high R. waves , major arrhythmias , and blocks . Some clinical ly relevant ECG combination of abnormalities were also analyzed . Six-year mortality from coronary heart disease ( CHD ) , cardiovascular diseases ( CVD ) and all-cause mortality ( ALL ) were the end-point . Those ECG findings were relatively common and covered the majority ( 80 to 90 % ) of all abnormalities found in the general population before excluding subjects with symptomatic heart disease . Most ECG findings on most occasions were associated with an excess mortality from the three end-points in both men and women and among relatively young ( age 30 - 49 ) and mature ( age 50 - 69 ) adults . The strongest predictor of fatal events were Q-QS items and blocks . The most consistent predictors were ST-T findings , although this was true for men and not for women . Relative risk against the absence of abnormalities ( one by one and all together ) were adjusted by multivariate analysis feeding in the models some possible confounders , i.e. age , systolic blood pressure , serum cholesterol , cigarette consumption and body mass index . Relative risks in cells with more than 20 events ( cells being separately made by men , women , the 5 ECG findings categories and the 3 end-points ) were ranging 1.00 to 9.88 for Q-QS abnormalities , 1.03 to 3.76 for ST-T abnormalities , 1.28 to 5.14 for high R waves , 0.81 to 2.28 for arrhythmias and 0.79 to 3.59 for blocks . Most of these relative risks were statistically significant . Combinations of clinical ly relevant ECG findings in the same individual ( LVH , possible and definite myocardial infa rct ion ) were rare but carried a severe prognosis with high and statistically significant relative risks among men ( ranging between 3.19 and 7.24 ) while they could not be properly tested in most cells for women due to the small numbers involved . It is concluded that in the general population high rates of prevalent ignored ECG abnormalities in asymptomatic subjects are associated with significant excess mortality from CHD , CVD and all-cause mortality , suggesting a high prevalence of silent heart disease OBJECTIVES This study was conducted to determine the incidence of physiologically significant coronary artery disease in a group of asymptomatic high risk men with essential hypertension and to assess the validity of noninvasive tests in a subset of these patients undergoing coronary arteriography . METHODS Two hundred twenty-six asymptomatic men ( mean age 61 + /- 8 years ) with essential hypertension and no clinical evidence of coronary artery disease but with at least one additional coronary risk factor were studied prospect ively . Fifty age- and risk factor-matched normotensive subjects were evaluated as a control group . After a minimum of 4 days without medication , subjects underwent stress thallium-201 scintigraphy , exercise and 48-h ambulatory electrocardiography , and echocardiography . Coronary angiography was performed in a subset of 34 ( 40 % ) of 84 patients with one or more positive test results . RESULTS A positive  thallium-201 scintigram  ( 18 % vs. 6 % ; odds ratio 3.4 , confidence interval 0.95 to 10.8 , p = 0.056 ) ,  exercise electrocardiograms ( ECGs ) ( 37 % vs. 13 % ; odds ratio 4.1 , confidence interval 1.5 to 11.2 , p < 0.003 ) and ambulatory ECG  ( 15 % vs. 0 % , p < 0.05 ) were more common in the hypertensive group than in the control group . In the cohort undergoing coronary angiography , thallium-201 scintigraphy was both sensitive and specific for epicardial atherosclerotic coronary disease ( 90 % and 79 % , respectively ) , but positive exercise and ambulatory ECGs occurred frequently in the absence of significant coronary stenoses . In the 39 % of hypertensive patients who had mild to moderate left ventricular hypertrophy , positive exercise and ambulatory ECGs occurred at a higher rate . CONCLUSIONS These findings suggest that physiologically significant coronary artery disease occurs more frequently in asymptomatic hypertensive men than in comparable normotensive control subjects . In the subgroup undergoing coronary arteriography , reversible scintigraphic defects were both sensitive and specific for diagnosing epicardial coronary artery disease , but exercise and ambulatory ECGs appeared to yield frequent false positive results , especially when left ventricular hypertrophy was present . These results indicate that patients with " silent " coronary artery disease can be identified among high risk hypertensive patients , but the appropriate application of such screening in clinical practice remains to be determined The objective of this report is the development of a population -specific prediction rule based on clinical and exercise test data that would estimate the risk of cardiovascular death in patients selected for cardiac catheterization . Prospect i ve data and follow-up information were obtained from patients who underwent cardiac catheterization soon after clinical assessment and exercise testing . Males ( n = 588 ) referred for evaluation of coronary heart disease from 1984 to 1990 were selected after exclusion of patients with significant valvular heart disease and patients with prior cardiac surgery . Half had a prior myocardial infa rct ion and half complained of typical angina pectoris . All patients performed a treadmill test and were selected for clinical reasons to undergo coronary angiography within 3 months . Over a mean follow-up period of 2.5 years ( + /- 1.4 years ) , there were 39 cardiovascular deaths and 45 nonfatal myocardial infa rct ions . The Cox proportional hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death : history of congestive heart failure ( hazards ratio of 4 ) , ST depression on the resting ECG ( hazards ratio of 3 ) , and a drop in systolic blood pressure below the resting value during exercise ( hazards ratio of 5 ) . Exercise-induced ST depression was not associated with either death or nonfatal myocardial infa rct ion . A simple score based on one item of clinical information ( history of congestive heart failure ) , a resting ECG finding ( ST depression ) , and an  exercise test response ( exertional hypotension ) stratified our patients for 4 years after testing from 75 % with a low risk ( annual cardiac mortality rate of 1 % ) , 17 % with a moderate risk ( annual mortality rate of 7 % ) , and 1 % with a high risk ( annual cardiac mortality rate of 12 % , with a hazards ratio of 20 and 95 % confidence interval from 6 to 70X ) . It was concluded that the variables available from the usual noninvasive workup of patients with known or suspected coronary artery disease enable prediction of risk of cardiovascular death . Three quarters of those usually undergoing cardiac catheterization can be identified by simple noninvasive variables as being at such low risk that invasive intervention is unlikely to improve prognosis The associations of many electrocardiographic ( ECG ) abnormalities at rest with incident coronary heart disease ( CHD ) are not completely established , and whether individual ECG abnormalities convey similar risk across gender and race is uncertain . We studied the independent association of several ECG findings with incident CHD , testing for effect modification by gender and race , in a large , population -based , prospect i ve cohort study . Findings from the baseline 12-lead electrocardiograms in 1987 to 1989 were classified according to the Minnesota Code in 12,987 black and white men and women , aged 45 to 64 years , who were initially free of CHD and the use of specific cardiac medications . The incidence of CHD was ascertained through 2000 . After adjustment for multiple cardiovascular risk factors , the ECG findings that had the highest hazard rate ratios ( HRRs ) for incident CHD , when considered singly , were left ventricular hypertrophy with ST-T strain pattern in white men ( HRR 6.50 ) and in black women ( HRR 2.31 ) and , in the whole cohort , major ( HRR 2.27 ) and minor ( HRR 2.47 ) ST depression and major T-wave abnormalities ( HRR 2.12 ) . Statistically significant associations were also found in the whole cohort for minor Q waves and left ventricular hypertrophy by the Cornell definition , but not for a prolonged QTc interval , major ventricular conduction defects , or ST elevation . In conclusion , several 12-lead ECG findings were independently associated with incident CHD in middle-aged adults . With only a few exceptions , the associations were similar for blacks and whites Objective To study abnormalities in the resting ECG as independent predictors for all cause , cardiovascular disease ( CVD ) , and coronary heart disease ( CHD ) mortality in a population based r and om sample of men and women , and to explore whether their prognostic value is different between sexes . Design and subjects An age and sex stratified r and om sample was selected from the total Belgian population aged 25 to 74 years .  Baseline data were gathered and resting ECGs were classified according to Minnesota code criteria . The sample was then followed for at least 10 years with respect to cause specific death . Results are based on observations from 5208 men and 4746 women free from prevalent CHD at the start of the follow up period . Results Although the prevalence of major abnormalities in general was comparable between sexes , women had more ischaemic findings , ST segment changes , and abnormal T waves on their baseline ECG , while men showed more arrhythmias , bundle branch blocks , and left ventricular hypertrophy . Fitting the multiplicative effect on subsequent mortality between all ECG classifications under study and sex indicated that the prognostic value of ECG changes was equal in women and men . Independently of other risk factors and other major ECG changes , almost all ECG classifications were significantly related to all cause , CVD , and CHD mortality . The most predictive ECG findings for CVD death were ST segment depression ( risk ratio ( RR ) 4.71 ) , major ECG findings ( RR 3.26 ) , left ventricular hypertrophy ( RR 2.79 ) , bundle branch blocks ( RR 2.58 ) , T wave flattening ( RR 2.47 ) , ischaemic ECG findings ( RR 2.35 ) , and arrhythmias ( RR 2.15 ) . The prognostic value of major ECG findings for CVD and CHD death was more powerful than well established cardiovascular risk factors . Conclusions Abnormalities in the baseline ECG are strongly associated with subsequent all cause , CVD , and CHD mortality . Their predictive value was similar for men and women Objective . To evaluate whether routinely performed ECGs in older people from the general population have added value for cardiovascular risk management beyond the information that is already available from their medical records . Design . Observational , prospect i ve cohort study . Setting . General population . Subjects . A total of 566 participants aged 85 years ( 377 women , 189 men ) . Methods . Lifelong history of cardiovascular disease was assessed through medical records obtained from general practitioners . Baseline ECGs were evaluated for prior myocardial infa rct ion and atrial fibrillation . During a 5-year follow-up period , complete cardiovascular mortality and morbidity data were gathered . Results . During 5 years of follow-up , 262/566 ( 46 % ) participants died , of whom 102/262 ( 39 % ) died from cardiovascular disease . Participants with a history of cardiovascular disease at age 85 years ( 284/566 , 50 % ) had an increased cardiovascular mortality ( HR 2.7 , 95 % CI 1.8–4.1 ) and morbidity ( HR myocardial infa rct ion 2.1 , 95 % CI 1.3–3.6 ; HR stroke 2.7 , 95 % CI 1.6–4.9 ) compared with those without such a history . Participants with major ECG abnormalities ( 102/566 , 18 % ) had an increased cardiovascular mortality ( HR 1.8 , 95 % CI 1.1–2.8 ) , but no increase of cardiovascular morbidity compared with those without major ECG abnormalities . In both participants with and without a history of cardiovascular disease , the presence of major ECG abnormalities was not associated with increased cardiovascular mortality or morbidity . Conclusions . In older people from the general population , a history of cardiovascular disease is a strong predictor of cardiovascular mortality and morbidity . Although abnormal findings on routine ECGs predict cardiovascular mortality , they do not provide additional prognostic information beyond the information available from medical records . Therefore , when accurate medical records are available , programmatic ECG recording is not effective in older people The Social Insurance Institution 's Coronary Heart Disease Study is a prospect i ve population study design ed to investigate the prevalence , risk factors and incidence of coronary heart disease ( CHD ) in middle-aged Finnish men and women . The study population consisted of 5 738 men and 5 224 women , aged 30 - 59 years at entry , drawn from 12 cohorts from south-western , western , central and eastern Finl and . The cohorts consisted of whole or r and om sample s of rural or semiurban dwellers or employees of a factory . The participation rate was 90 per cent . The prevalence of symptoms was determined by the Rose question naire and abnormalities on resting ECG were coded according to the Minnesota code . Blood pressure , smoking habits , serum cholesterol , triglycerides , postload plasma glucose and obesity were the risk factors analysed at the baseline examination . The mortality of examinees has been followed continuously . This report deals with the main findings at the baseline examination and the mortality follow-up experience in 5 years . The prevalence of typical angina pectoris was 4.4 per cent in men and 5.4 per cent in women . Unequivocal ECG signs of past myocardial infa rct ion were observed in 1.0 per cent of men and 0.3 per cent of women . Other ECG findings suggesting CHD were observed in 9.2 per cent of men and 11.1 per cent of women . The 5-year mortality was 4.3 per cent in men and 0.9 per cent in women . Men with typical chest pain symptoms had a seven-fold risk to die from CHD , compared to men without symptoms . Men with ECG abnormalities compatible with an old infa rct ion had a 19.5-fold and men with other ECG findings suggesting CHD a 7.1-fold risk to die from CHD compared to men without resting ECG abnormalities . Men with ECG findings as the only indicator of CHD had worse survival than men with symptoms as the only indicator of CHD . The value of symptoms and ECG findings as predictors of CHD mortality in women was very low Although the total number of deaths attributed to cardiovascular disease has decreased during recent decades , an increase in the percentage of cardiac deaths occurring suddenly ( from 56 % in 1989 to 63 % in 1998 ) has actually result ed in an increase in the total number of sudden deaths in the United States.1 The problem of sudden death spans all racial and cultural groups and is equally important in men and women . It is now 40 years since continuous ECG monitoring revealed that ventricular tachycardia and ventricular fibrillation ( VT/VF ) are responsible for the majority of sudden deaths . Dissemination of this information result ed in a marked change in practice . Until the 1970s , physicians treated only symptomatic VTs . Therapeutic options were limited to a few antiarrhythmic drugs , administered empirically . With the advent of telemetric ECG monitoring and continuous ambulatory ( Holter ) ECG monitoring came the recognition that frequent and multiform ventricular ectopy often preceded episodes of VF in the acute phase of myocardial infa rct ion ( MI ) . Ventricular ectopy and nonsustained VT was documented 1 to 2 weeks after MI in many patients . The presence of frequent ventricular premature complexes and runs of nonsustained VT in patients with significant left ventricular dysfunction were then demonstrated to be an independent predictor of sudden cardiac death late after MI . This information then led to the practice of administering antiarrhythmic drugs to suppress ventricular ectopy under the presumption that suppression of asymptomatic ectopy would prevent sudden death . This fashion lasted almost 20 years , until the results of the Cardiac Arrhythmia Suppression Trial ( CAST ) trial demonstrated the harm caused by this approach.2 Thus , a sea change in the practice of cardiology had occurred , from treating only symptomatic patients to therapy aim ed at primary prevention of sudden death . The initial efforts using antiarrhythmic drugs failed to reduce mortality . While many physicians in the 1970s were administering prophylactic drugs to survivors of MI , Michel Mirowski was developing the implantable cardioverter-defibrillator ( ICD ) , introduced to clinical medicine in 1980.3 It took more than a decade before r and omized , controlled trials evaluating the ability of ICDs to reduce mortality in survivors of cardiac arrest or sustained VT appeared in print . These studies demonstrated the superiority of ICDs over amiodarone and other pharmacological agents for secondary prevention of sudden death in survivors of cardiac arrest.4–7 After publication of the secondary -prevention studies , 3 trials were published demonstrating that ICDs could reduce mortality in patients with chronic coronary disease BACKGROUND The mortality rate among patients with coronary artery disease , abnormal ventricular function , and unsustained ventricular tachycardia is high . The usefulness of electrophysiologic testing for risk stratification in these patients is unclear . METHODS We performed electrophysiologic testing in patients who had coronary artery disease , a left ventricular ejection fraction of 40 percent or less , and asymptomatic , unsustained ventricular tachycardia . Patients in whom sustained ventricular tachyarrhythmias could be induced were r and omly assigned to receive either antiarrhythmic therapy guided by electrophysiologic testing or no antiarrhythmic therapy . The primary end point was cardiac arrest or death from arrhythmia .  Patients without inducible tachyarrhythmias were followed in a registry . We compared the outcomes of 1397 patients in the registry with those of 353 patients with inducible tachyarrhythmias who were r and omly assigned to receive no antiarrhythmic therapy  in order to assess the prognostic value of electrophysiologic testing . RESULTS Patients were followed for a median of 39 months . In a Kaplan-Meier analysis , two-year and five-year rates of cardiac arrest or death due to arrhythmia were 12 and 24 percent , respectively , among the patients in the registry , as compared with 18 and 32 percent among the patients with inducible tachyarrhythmias who were assigned to no antiarrhythmic therapy ( adjusted P<0.001 ) . Overall mortality after five years was 48 percent among the patients with inducible tachyarrhythmias , as compared with 44 percent among the patients in the registry ( adjusted P=0.005 ) . Deaths among patients without inducible tachyarrhythmias were less likely to be classified as due to arrhythmia than those among patients with inducible tachyarrhythmias ( 45 and 54 percent , respectively ; P=0.06 ) . CONCLUSIONS Patients with coronary artery disease , left ventricular dysfunction , and asymptomatic , unsustained ventricular tachycardia in whom sustained ventricular tachyarrhythmias can not be induced have a significantly lower risk of sudden death or cardiac arrest and lower overall mortality than similar patients with inducible sustained tachyarrhythmias Background —Exercise stress testing alone or with perfusion imaging is the st and ard screening method to determine the presence of obstructive coronary artery disease ( CAD ) in people with chest pain . In asymptomatic individuals with a family history of premature CAD , it is unclear whether abnormalities on these functional exercise tests represent significant coronary disease . Methods and Results —An abnormal exercise test , thallium scan , or both occurred in 153 ( 21 % ) of 734 asymptomatic siblings of persons with documented CAD , of whom 105 underwent coronary angiography with quantitative analysis of stenosis severity . Overall , 95 % had coronary atherosclerosis , but only 39 % had 1 or more stenoses with ≥50 % narrowing . Of 30 siblings in whom the exercise test and perfusion scan were both abnormal , 70 % had ≥50 % stenoses . The mean stenosis in arteries that fed perfusion defects was only 43±31 % , and 68 % of such stenoses were < 50 % . However , in 71 % of all defects , the location matched arteries with the most severe stenoses . Conclusions —In asymptomatic persons with a family history of CAD , abnormal exercise scintigraphy identifies predominantly mild coronary atherosclerosis . Perfusion defects may be caused by coronary vasomotor dysfunction in addition to atherosclerotic plaque BACKGROUND AND OBJECTIVES In hemodialysis , applicable guidelines recommend regular electrocardiogram ( ECG ) recordings . However , respective systematic evaluations are absent . Thus , the authors investigated whether routine ECG findings add prognostic information to st and ard risk assessment in hemodialysis . DESIGN , SETTING , PARTICIPANTS , & MEASUREMENTS The relationship between nine common baseline ECG variables and a combined cardiovascular endpoint ( CVE ; cardiac death , myocardial infa rct ion , stroke ) , sudden death , stroke , MI , and all-cause death in 1253 patients from the German Diabetes and Dialysis Study was evaluated . All patients were on maintenance hemodialysis , had type 2 diabetes mellitus , and received r and omized treatment with atorvastatin or placebo .  RESULTS During 4 yr of follow-up ( March 1998 to March 2004 ) , 469 patients reached the CVE , and 617 died . After adjustment for demographics , comorbidities , and biomarkers in multivariate analysis , patients presenting without sinus rhythm were 89 % more likely to die , and the risk of CVE and stroke increased by 75 % and 164 % , respectively , compared with patients with preserved sinus rhythm . Left ventricular hypertrophy was associated with > 2-fold increase in the risk of stroke and a 60 % increase in the risk of sudden death . CONCLUSIONS In hemodialysis patients with type 2 diabetes mellitus , the absence of sinus rhythm is a risk indicator for CVE , stroke , and all-cause death , and left ventricular hypertrophy is associated with stroke and sudden death . Thus , routine ECG recording adds prognostic information to st and ard risk assessment OBJECTIVES To identify pre-hospital predictors of a ) death or the development of cardiovascular complications during hospitalisation ( primary objective ) and b ) all-cause death during one year of follow-up ( secondary objective ) , in chest pain patients with suspected acute coronary syndrome ( ACS ) . METHODS A prospect i ve study that comprised patients in western Sweden , who were transported to hospital by the emergency medical service ( EMS ) due to chest pain and suspected ACS .  Multiple logistic regression was used to identify independent predictors of adverse outcomes . RESULTS Among all 1600 eligible patients , 21 % died or had a cardiovascular complication during hospitalisation and 10 % died during one year of follow-up . Nine factors were identified pre-hospitalisation as independent predictors of death or cardiovascular complications during hospitalisation . They were increasing age , a history of congestive heart failure , nausea and /or vomiting , rapid breathing rate , low oxygen saturation , high heart rate , together with ST-segment elevation , ST-segment depression and right bundle branch block on the pre-hospital electrocardiogram ( ECG ) . For the secondary objective of death during one year of follow-up , the following five factors were identified as independent predictors : increasing age , a history of congestive heart failure , dyspnea , low oxygen saturation and left bundle branch block on the pre-hospital ECG . CONCLUSIONS In the pre-hospital setting of chest pain and suspected ACS , we identified nine predictors of the primary adverse outcome . They were factors representing previous history , symptoms and ECG findings . This information may contribute to the development of a decision support system for the EMS , which then needs to be clinical ly tested Exercise testing in asymptomatic persons has been criticized for failing to accurately predict those at risk for coronary heart disease ( CHD ) . Previous studies on asymptomatic subjects , however , may not have been large enough or long enough to provide reliable outcome measures . This study examines the ability of a maximal exercise test to predict death from CHD and death from any cause in a population of asymptomatic men . This is a prospect i ve longitudinal study performed between 1970 and 1989 , with an average follow-up of 8.4 years . The subjects are 25,927 healthy men , 20 to 82 years of age at baseline ( mean 42.9 years ) who were free of cardiovascular disease and who were evaluated in a preventive medicine clinic . The main outcome measures are CHD mortality and all-cause mortality . During follow-up there were 612 deaths from all causes and 158 deaths from CHD . The sensitivity of an abnormal exercise test to predict coronary death was 61 % . The age-adjusted relative risk of an abnormal exercise test for CHD death was 21 ( 6.9 to 63.3 ) in those with no risk factors , 27 ( 10.7 to 68.8 ) in those with 1 risk factor , 54 ( 21.5 to 133.7 ) in those with 2 risk factors , and 80 ( 30.0 to 212 . 5 ) in those with > /=3 factors . A maximal exercise test performed in asymptomatic men free of cardiovascular disease does appear to be a worthwhile tool in predicting future risk of CHD death . An abnormal exercise test is a more powerful predictor of risk in those with than without conventional risk factors We prospect ively studied 135 asymptomatic normotensive subjects with exercise-induced ST ischemic depression of 1 mm or more and compared them with 379 controls . At least two controls with negative responses on the exercise electrocardiographic ( EKG ) test  were selected for each case and were matched for age , sex , work , community , and coronary-risk-factors index . The end points considered were the following coronary events : angina pectoris , myocardial infa rct ion , and sudden death . After a median follow-up period of 6.0 years for the cases and 6.4 years for the controls , the relative risk was 5.55 ( 95 per cent confidence limits , 2.75 to 11.22 ) . Coronary events occurred significantly earlier in the cases than in the controls . Our data also suggest that the  exercise EKG response is a particularly good prognostic indicator for myocardial infa rct ion . In addition , our analysis has confirmed the predictive roles of age , smoking , blood pressure , and the coronary-risk-factors index and suggests that the  exercise EKG response is an additional independent risk indicator for coronary events Background Previous studies have shown that ST depressions ≤ 1.0 mm during or post-exercise increase long-term risk of dying from coronary heart disease ( CHD ) , the need for coronary artery bypass grafting ( CABG ) or the development of acute myocardial infa rct ion ( AMI ) in healthy men . In the present prospect i ve cohort study we investigate whether less marked ST depressions may influence CHD mortality , incidence of AMI , the need for a CABG or having a non-fatal stroke . Methods During 1972–75 , 2014 men aged 40–59 years , free from somatic diseases and not using any drugs , underwent an  examination programme including case history , clinical examination , various blood tests and a symptom-limited exercise ECG-test . ECG was registered during exercise and at 30 s , 1 , 2 , 3 and 5 min post-exercise . The possible prognostic impact of ST-changes of 0.50–0.99 mm and ≤ 1.00 mm compared with normal ST-segments were studied separately and combined . Horizontal , down-sloping and slowly up-sloping ST-segment patterns were combined . Results After adjustment for age , smoking , blood pressure , cholesterol , maximal heart rate , left ventricular hypertrophy and physical fitness ST depressions ≤ 0.50 mm - during and /or post-exercise - were associated with a 1.47-fold [ 95 % confidence interval ( CI ) 1.10–1.95 ] , and 1.54-fold ( 95 % CI of 1.17–2.04 ) increased 26 years risk of CHD-mortality , respectively . The same ST-changes also increased 22 years risk of developing non-fatal AMI or needing CABG but not developing non-fatal stroke . Conclusions Even an ST depression ≤ 0.50 mm during and /or after exercise increases the long-term risk of CHD-death , developing an AMI or needing CABG . No association was found between ST-changes and incidence of non-fatal strokes CONTEXT Data are sparse regarding the prevalence , incidence , and independent prognostic value of minor and /or major electrocardiographic ( ECG ) abnormalities in asymptomatic postmenopausal women . There is no information on the effect , if any , of hormonal treatment on the prognostic value of the ECG . OBJECTIVE To examine association of minor and major baseline and incident ECG abnormalities with long-term cardiovascular morbidity and mortality . DESIGN , SETTING , AND PARTICIPANTS Post-hoc analysis of the estrogen plus progestin component of the Women 's Health Initiative study , a r and omized controlled primary prevention trial of 14 749 postmenopausal asymptomatic women with intact uterus who received 1 daily tablet containing 0.625 mg of oral conjugated equine estrogen and 2.5 mg of medroxyprogesterone acetate or a matching placebo . Participants were enrolled from 1993 to 1998 , and the estrogen plus progestin trial was stopped on July 7 , 2002 . MAIN OUTCOME MEASURES The Novacode criteria were used to define minor , major , and incident ECG abnormalities . Cardiovascular end points included incident coronary heart disease ( CHD ) and cardiovascular disease ( CVD ) events . RESULTS Among women with absent ( n = 9744 ) , minor ( n = 4095 ) , and major ( n = 910 )  ECG abnormalities  , there were 118 , 91 , and 37 incident CHD events , respectively . The incident annual CHD event rates per 10 000 women with absent , minor , or major ECG abnormalities were 21 ( 95 % confidence interval [ CI ] , 18 - 26 ) , 40 ( 95 % CI , 32 - 49 ) , and 75 ( 95 % CI , 54 - 104 ) , respectively . After 3 years of follow-up , 5 % of women who had normal ECG at baseline developed new ECG abnormalities with an annual CHD event rate of 85 ( 95 % CI , 44 - 164 ) per 10 000 women . The adjusted hazard ratios for CHD events were 1.55 ( 95 % CI , 1.14 - 2.11 ) for minor baseline , 3.01 ( 95 % CI , 2.03 - 4.46 ) for major baseline , and 2.60 ( 95 % CI , 1.08 - 6.27 ) for incident ECG abnormalities . There were no significant interactions between hormone treatment assignment and ECG abnormalities for risk prediction of cardiovascular end points . For prediction of CHD events , the addition of ECG findings to the Framingham risk score increased from 0.69 to 0.74 the area under the receiver operating characteristic curve . Similar findings were found for incident CVD events . CONCLUSIONS Among asymptomatic postmenopausal women , clinical ly relevant baseline and incident ECG abnormalities are independently associated with increased risk of cardiovascular events and mortality , and the information is incremental to the established method of risk stratification . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00000611
Evidence on harms was limited , but direct harms seemed minimal ( for resting ECG ) or small ( for exercise ECG ) .
BACKGROUND Coronary heart disease is the leading cause of death in adults .
Screening for abnormalities by using resting or exercise electrocardiography ( ECG ) might help identify persons who would benefit from interventions to reduce cardiovascular risk .
PURPOSE To up date the 2004 U.S. Preventive Services Task Force evidence review on screening for  resting or exercise ECG abnormalities in asymptomatic adults .