Pay attention to the following lines from the article: Mandrola's last pet peeve is excessive heart rhythm screening among asymptomatic individuals, particularly in the age of wearable devices. The main issue is that continuous monitoring with mobile devices, either medical devices or a smartwatch, often pick up episodes of atrial fibrillation of short duration that would have gone undetected 10-15 years ago when the standard of care was a single 12-lead EKG. "These cardiac devices can pick up 1 hour or 3 hours of atrial fibrillation, which would probably be best not to know about," he said.

Mandrola, a frequent contributor to Medscape, has his own list of top three unnecessary tests, and CAC tops the list. For CAC he described two scenarios that lead to superfluous testing: patients who are already taking statins who get sent for CAC testing, and CAC testing to evaluate patients with atypical chest pain who are at low risk for having a myocardial infarction. For these patients, CAC is usually incidental and not related to what is often non-cardiac chest pain.

Next on his list? Too much stress testing. In addition to the Choosing Widely recommendation to avoid stress testing for workup of palpitations or syncope, Mandrola often sees stress tests used to rule out cardiac causes of chest pain in patients at little risk for ASCVD. He pointed out that troponin testing is a much better tool for diagnosing a heart attack

"If someone comes in with very atypical pain, has a low pretest probability of ischemic heart disease, and has negative troponin testing, there's very little reason to do stress testing," He said.

Mandrola's last pet peeve is excessive heart rhythm screening among asymptomatic individuals, particularly in the age of wearable devices. The main issue is that continuous monitoring with mobile devices, either medical devices or a smartwatch, often pick up episodes of atrial fibrillation of short duration that would have gone undetected 10-15 years ago when the standard of care was a single 12-lead EKG. "These cardiac devices can pick up 1 hour or 3 hours of atrial fibrillation, which would probably be best not to know about," he said.

Why not? Not every patient with AFib needs treatment. Data suggest cardioversion of patients with recent onset (< 36 hours) symptomatic AFib may be safely delayed, and that in some cases patients with brief episodes of atrial arrhythmia resembling AFib may not benefit from oral anticoagulation, and may even carry higher risks of death or major bleeding.

Mandrola likes to quote Voltaire, who famously said, "The art of medicine consists of amusing the patient while nature cures the disease." For modern clinicians, that might translate into spending more time with patients weighing the risk and benefits of CAC and stress testing before opening Pandora's box.

To help clinicians put the presence of CAC in perspective, Tattersall and colleagues recently published a new analysis from a previously published prospective cohort study, the Multi-Ethnic Study of Atherosclerosis (MESA), which provided data on the prevalence of CAC in a group of individuals who were not previously diagnosed with ASCVD.

"We can basically frame the discussion between the patients and the physicians about what the expected prevalence of coronary calcium is based on their age, sex, race, ethnicity," Tattersall told Medscape Medical News.


The prevalence of a nonzero Agatston coronary artery calcification score rises with age. Adapted from Tattersall et al. JAMA Int Med. Sept. 25, 2023.

For example, the table in their recent research letter shows that 80% of adults over age 80 have detectable CAC, so a patient in that age group who has a low 10-year ASCVD score probably would not benefit from a prescription for statin. But only 17% of Black women aged 50-54 have detectable CAC. For those women, the finding of CAC could lead to a conversation between clinician and patient about whether to start statin therapy.

No Symptoms, No Test?
Friederike Keating, MD, a nuclear cardiologist and professor of medicine at the University of Vermont Medical Center in Burlington, often receives referrals for stress tests where the justification is "coronary calcification seen on a chest CT." She acknowledged that some of the referrals may be justified, but most are not.

"If somebody doesn't have any symptoms, and they just have calcium in their arteries, they should have a discussion with their doctor," Keating told Medscape. "But they shouldn't necessarily be referred to get a stress test if they otherwise don't have any symptoms."


Dr Friederike Keating

Keating headed the most recent cardiology workgroup for the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine that sought to generate informed patient physician conversations about unnecessary tests, procedures, and treatments across all internal medicine specialties. For the cardiology recommendations, titled "Five Things Physicians and Patients Should Question," her group tried to prioritize tests and procedures that are commonly ordered but not always needed.

CAC testing in patients already known to have ASCVD — and thus likely already taking a statin medication — made their top five list, along with advice to avoid obtaining routine serial echocardiograms in patients with chronic heart failure who are clinically stable. Another is to avoid routine imagine stress tests or coronary CT angiography for the workup of palpitations or presyncope.

Keating said she hopes reducing superfluous tests will help cut down on unexpected but ultimately meaningless findings: "We don't like to have too much in the way of incidental findings because you always get down testing rabbit holes, right?"

John Mandrola, MD, a cardiac electrophysiologist practicing in Louisville, Kentucky, has long been critical of CAC testing. "There is a theoretical harm of extra radiation," he said, "But I think the main risks that I worry about are the non–evidence-based downstream testing that comes of this."

Mandrola, a frequent contributor to Medscape, has his own list of top three unnecessary tests, and CAC tops the list. For CAC he described two scenarios that lead to superfluous testing: patients who are already taking statins who get sent for CAC testing, and CAC testing to evaluate patients with atypical chest pain who are at low risk for having a myocardial infarction. For these patients, CAC is usually incidental and not related to what is often non-cardiac chest pain.

Next on his list? Too much stress testing. In addition to the Choosing Widely recommendation to avoid stress testing for workup of palpitations or syncope, Mandrola often sees stress tests used to rule out cardiac causes of chest pain in patients at little risk for ASCVD. He pointed out that troponin testing is a much better tool for diagnosing a heart attack

"If someone comes in with very atypical pain, has a low pretest probability of ischemic heart disease, and has negative troponin testing, there's very little reason to do stress testing," He said.

Mandrola's last pet peeve is excessive heart rhythm screening among asymptomatic individuals, particularly in the age of wearable devices. The main issue is that continuous monitoring with mobile devices, either medical devices or a smartwatch, often pick up episodes of atrial fibrillation of short duration that would have gone undetected 10-15 years ago when the standard of care was a single 12-lead EKG. "These cardiac devices can pick up 1 hour or 3 hours of atrial fibrillation, which would probably be best not to know about," he said.

Why not? Not every patient with AFib needs treatment. Data suggest cardioversion of patients with recent onset (< 36 hours) symptomatic AFib may be safely delayed, and that in some cases patients with brief episodes of atrial arrhythmia resembling AFib may not benefit from oral anticoagulation, and may even carry higher risks of death or major bleeding.



link: https://www.medscape.com/viewa...029_etid6004676&uac=

This message has been edited. Last edited by: ZSMICHAEL,

Half of the article above is duplicative.

How about some Cliff notes for us guys that don't understand all the technical talk?

quote:

Originally posted by 229DAK:
Half of the article above is duplicative.

I didn't understand it either time.

I read all of that...twice. Sorry, but i would need a medical dictionary to even begin to understand/relate to any of it.

Maybe it's just me.

[quote]Half of the article above is duplicative.
^^^^^^^^^^^^
Sorry. I did not proofread. The copy and paste function is difficult for me. I think I fixed it. The gist of the article is overtesting of cardiac function and a subtle jab at wearable devices that measure heart rate etc. Think Kardia for example.
If you have had cardiac problems it is easier to understand.

I think the issue with over testing is the threat of liability in missing something causing those responsible to be overly cautious.

In my case, I pulled something in my chest wall, that led to shortness of breath from pain. This caused my BP to spike (I'm hypertensive).

Knowing that any chest pain will result in an expedited trip to the ER from any other medical provider, we went to the ER directly. I calmly explained to the triage the issue, and was still placed on a 12 lead right away.

Many DRs came and looked over the results numerous times, always saying that they couldn't see any abnormalities, but wanted to continue observations to be sure.

After 4 hours, I was finally given a pain med and muscle relaxer that reduced my pain and allowed my to catch a full deep breath.

Following another hour of observations, they discharged my with a follow up stress test in a few weeks. I passed the stress test with flying colors, causing then to roll their eyes at what they saw was a waste of time.

I can understand why this happened from a liability stance, but am still frustrated from my (patient's) perspective.

Oh, and I wear a Samsung watch, that we used to compare the stress test results (since nothing else was pressing). My watch pinged for A-fib a few times, but the cardio doc said it was picking up an echo, and falsely calling it A-fib (I'm sure it's set to err on the side of caution as well).

quote:

Next on his list? Too much stress testing. In addition to the Choosing Widely recommendation to avoid stress testing for workup of palpitations or syncope, Mandrola often sees stress tests used to rule out cardiac causes of chest pain in patients at little risk for ASCVD. He pointed out that troponin testing is a much better tool for diagnosing a heart attack

Maybe I’m reading this incorrectly but a stress test conducted as a precaution during a ER visit for a GI problem saved my ass. ER doc wanted to rule out everything, said he’d feel better to run the test which I agreed to.

Results, during the test I had a SHTF and went directly to the cardiac unit. Diagnosis, three severely blocked arteries. Twelve hours later I was under the knife.

quote:

Originally posted by shovelhead:
[QUOTE]Next on his list? Too much stress testing. In addition to the Choosing Widely recommendation to avoid stress testing for workup of palpitations or syncope, Mandrola often sees stress tests used to rule out cardiac causes of chest pain in patients at little risk for ASCVD. He pointed out that troponin testing is a much better tool for diagnosing a heart attack

Maybe I’m reading this incorrectly but a stress test conducted as a precaution during a ER visit for a GI problem saved my ass. ER doc wanted to rule out everything, said he’d feel better to run the test which I agreed to.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Glad it worked out for you. The author is talking about OVERutilization of stress testing which is unnecessary. A better example might be PET scans which frequently lead to needless exploratory surgeries.

I'd like to point out to those of you who might be critical of this thread- without contributors posting content, there would be nothing to read in this forum. With nothing to read, no one would visit. Without visitors, this forum is merely random bits on spinning hard drives in a server room.

ZSMICHAEL contributes to the forum some things which are of interest to him and which he feels might be of interest to others; not to all forum members of course, but very little of the content posted in this forum is universally interesting.

I want to take this opportunity to encourage all members to find or create subject matter which interests you and which you think might be of interest to others.

Some things you might post will generate little interest. Don't let this discourage you, because some things you post will lead to discussions that enlighten or inform or entertain others.

The Lounge of this forum demonstrates quite clearly that even though this is a firearms forum, it is not all about firearms.

You have other hobbies, other interests. You can do everyone here a favor by sharing such things with us.

And when you feel the need to be critical of a member's contributions, remember: a lack of new content means this place turns into a wasteland.

I have a new Garmin watch that can record my bike workouts and can track heart rate, pulse ox and do a 30 second ECG test that can detect A-fib. I've had heart surgery so I'm interested in all these metrics. I brought up the watch with my Doctor and he KNOWS he's going to get a lot more phone calls from patients as more and more people get this capability on their wrist.

In addition to para's remarks I'd make two points:

1. ZSMICHAEL: For some of the less-frequently-seen acronyms, expanding the acronym the first time it's used would be helpful. E.g.: "CAC". I figured out "Coronary Artery Calcium," but, others might never make the connection.

2. Critics who don't understand the article: I would urge you to spend the time to make the effort to understand things like this. It's your health. If you don't understand the mechanics of your health you're at the mercy of those in the health "care" industry who claim they do. IME the health "care" industry does not always necessarily have your best interests at heart.

Coincidentally (I posted about this earlier): I had a Calcium Score done at my own request and on my own dime earlier this year. It's a relatively inexpensive test. (Insurance usually doesn't cover it.) It turned up some concerns. Enough that a scheduled (unrelated, minor) surgery was belayed and a cardio stress test done, instead. (I passed the stress test with flying colors. Cardiologist suggested, based upon the stress test, the calcium was probably on the outside of the arteries, rather than the inside.)

quote:

Originally posted by parabellum:
And when you feel the need to be critical of a member's contributions, remember: a lack of new content means this place turns into a wasteland.

I sincerely apologize for my post coming across as criticism. I had intended more to be poking fun at myself for not being able to understand it. I much prefer content that is difficult to grasp to content that is so dumbed down that it is borderline useless.

The mind is a muscle. It needs to be exercised and given challenges it can't quite grasp.

Often even when I can't understand a subject, it gives clues that if followed can be useful.

Sigforum? Why go anywhere else?

I only skimmed the article, but the basic premise I got is that with various types of testing being more available nowadays, there tends to be over testing done, and therefore the discovery of medical abnormalities that are otherwise benign, which leads to overtreatment.

^^^^^^

Yes. Cancer screening in asymptomatic patients is another one. Mandrola does periodic You Tube discussions with an oncologist/epidemiologist Dr Vinay Prassad.

I’m not in the medical biz, just an Iwatch user and interested party.
These wearables are right on the edge of being a major factor in providing important early warning data for consumers. Some features are there now.
Another generation or two will have real potential to improve health outcomes at a much more affordable cost.
Even though the article had some technical terms, I’m getting used to having Google at my side to interpret my own test results so it wasn’t that hard to understand the important parts.

Over testing really makes you want to VOMIT.

Q, BMJ remains the only trustworthy major medical journal IMO; your tease gets the point across, I think.
Going back to The House of God which we read as interns ourselves: if you don’t take the temperature you can’t find a fever.

Anyway, I do agree with ZSMICHAEL’s posted article, both times.
Test ordering should be focused on signs and symptoms. There are a limited number of screening tests proven to give better outcomes than not screening. Otherwise we could spend the entire health care budget “screening”, which ends up with vast numbers of false positives which have to be followed up—all with some risk.

I spent collectively years of my life trying to get “chest pain” patients with clearly non-angina pain sent home without a stress test.

It's interesting, my wife recently had what appears to have been a cardiac episode and her new Cardiologist recommended a Kardia in lieu of a traditional monitor. He said for folks with irregular rhythm he hasn't used a traditional monitor for several years now.

The only thing I do worry about is her over analyzing the data that her watch is telling her. It's almost become a habit for her to look at her watch every few minutes to see HR or O2 levels.

My cardiac doctor (of five days) would not release me from the hospital with out me agreeing to wear a life vest... diffibulating device. His explanation was that I only had a 2% chance of having another heart attack in the next 6 months but the statistics showed in the past that those that did ...100% died. Wearing the vest was the best gamble... It was not that bad... especially since I was taking it easy and not working... but the dern thing would go off... alarm bad sensor or such about every other day....

As for the original article... yes, one can over analyze and over think this stuff..... but seems liability for not seeing something or blaming the Dr's for anything is the real issue. I was complaining to the lady who cuts my hair about my businesses liability insurance.. couple thousand dollars.. her husband is a doctor... his is 100K.