CHA Family Medicine Residency

Tufts family medicine residents have "the best of both worlds"

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When to stress test if low risk? Never!

Cardiac Screening With Electrocardiography, Stress Echocardiography,or Myocardial Perfusion Imaging:

Advice for High-Value Care From theAmerican College of Physicians

Ann Intern Med. 2015;162:438-447. doi:10.7326/M14-1225


Don’t “screen” low risk people with Stress EKG, Stress Echo or Persantine/MIBI perfusion – even the prior recommendation for men embarking on new exercise regimens.
So what is “low risk”?
Less than 7.5% 10 year ASCVD using the new risk calculator?
Or less than 10% using any calculator?
You decide. No consensus that I know of. But all the calculators overestimate risk:

 Ann Intern Med. 2015;162:266-275. doi:10.7326/M14-1281. An Analysis of Calibration and Discrimination Among Multiple Cardiovascular Risk Scores in a Modern Multiethnic Cohort


What I do is this: I use the new calculator (ASCVD Risk Estimator) for people aged 40-79. If less than 7.5%, no problem (but they can always improve). If 7.5% or higher, then push life-style modifications. If over 10%, push even harder. At some point consider a statin and ASA. Risk > 20%, Diabetes, ASCVD, LDL>190 – maybe they should be on High Intensity Statin like the ACC/AHA guide says, along with intensive risk factor modification. You know, it’s just a guideline.