Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 49-year-old man is evaluated during a routine examination. He is asymptomatic but is concerned about his risk for cardiovascular disease. Medical history is notable for hypertension. He is a nonsmoker, and he works as an executive at a highly successful company. Family history is noncontributory. His only medication is hydrochlorothiazide.

On physical examination, the patient is afebrile, blood pressure is 118/78 mm Hg, and pulse rate is 78/min. BMI is 31. The remainder of the physical examination is normal.

Results of laboratory studies show a serum total cholesterol level of 190 mg/dL (4.92 mmol/L) and a serum HDL cholesterol level of 46 mg/dL (1.19 mmol/L). Fasting plasma glucose level is 95 mg/dL (5.27 mmol/L).

His estimated 10-year risk of atherosclerotic cardiovascular disease using the Pooled Cohort Equations is 3.2%.

In addition to diet and exercise, which of the following is the most appropriate next step in management?

A: Coronary artery calcium scoring
B: Exercise electrocardiography
C: Resting electrocardiography
D: No further testing

MKSAP Answer and Critique

The correct answer is D: No further testing.

This patient needs no further testing. Although he is obese and has a history of hypertension, he is at low risk for cardiovascular disease. Risk assessment for atherosclerotic cardiovascular disease (ASCVD) has traditionally been with the Framingham risk score, although the American College of Cardiology/American Heart Association Pooled Cohort Equations, a new method for assessment that includes additional variables for risk stratification, is increasingly being used. With this method, a 10-year risk of ASCVD of less than 5% is considered low risk, 5% to below 7.5% is considered intermediate risk, and 7.5% and above is designated as high risk. This patient has a calculated 10-year risk of 3.2%, making him at low risk for ASCVD. Therefore, no additional testing is indicated at present.

Patients at low risk for cardiovascular disease, such as this one, do not benefit from aggressive risk factor modification and therefore would not benefit from screening using nontraditional risk factors, such as coronary artery calcium scoring. The U.S. Preventive Services Task Force (USPSTF) concludes that there is insufficient evidence to assess the balance of benefits and harms for using nontraditional risk factors to screen asymptomatic, intermediate-risk patients without a history of coronary heart disease. Nontraditional risk factors include ankle-brachial index, CT to assess coronary artery calcification, high-sensitivity C-reactive protein, carotid intima-media thickness, homocysteine, and lipoprotein(a) level. Furthermore, the Society of Cardiovascular Computed Tomography, through the Choosing Wisely campaign, advises against ordering coronary artery calcium scoring for screening purposes in asymptomatic individuals who are at low risk for cardiovascular disease except for those with a family history of premature coronary artery disease.

The USPSTF and the American College of Physicians recommend against resting or exercise electrocardiography (ECG) for cardiovascular disease screening in asymptomatic adults who are at low risk for cardiovascular events. This patient is asymptomatic and is at low risk for cardiovascular disease; therefore, resting and exercise ECG are not indicated. For individuals at intermediate risk for cardiovascular disease, the USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms for screening with resting or exercise ECG.

Key Point

• In asymptomatic patients at low risk for cardiovascular disease, cardiac testing is unnecessary.

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