The 53-year-old accountant, a longtime patient of Marvin M. Lipman, Consumer Reports’ chief medical adviser, was smiling when he came in for a routine exam after a winter in Florida. “I guess I’m going to live forever,” he said. “My coronaries are clean.”
He explained that a golf buddy had persuaded him to get a checkup from a local cardiologist, something Lipman never thought the man needed because his health was good and he had no risk factors for cardiovascular disease.
Evidently, the Florida cardiologist didn’t agree. He put the unquestioning accountant through what he called routine testing. That included an electrocardiogram and a stress echocardiogram (imaging of the heart by sonography before and after a standard treadmill exercise test). Apparently still not satisfied, the doctor ordered a four-hour nuclear stress test, in which a radioactive material is injected before and after exercise, and its eventual distribution in the heart muscle is recorded by a radiation detector. He concluded there was a problem. (It turned out that the “problem” was an abnormality in the images caused by the patient’s movement during the test.)
A day or two later the patient, by now convinced he was at death’s door and would need open-heart surgery, found himself at a hospital, in a darkened X-ray room, undergoing a coronary angiogram. The procedure involves the insertion, usually into a groin artery, of a flexible tube that is threaded up into the heart. Dye is then injected to outline the coronary arteries and reveal any blockages.
“When he told me that my arteries were clean, I was the happiest man in the world,” the patient told Lipman. “No matter that I wound up with bleeding in my groin and unable to play golf for three weeks.”
The indications for cardiac screening tests for people without symptoms or a history of coronary disease haven’t changed much through the years. The tests mentioned probably don’t add much to diagnosis and treatment over and above what can be learned from knowing a person’s risk factors.
Those risk factors are heredity (a parent or sibling who had a heart attack at an early age), smoking, hypertension, diabetes, elevated LDL cholesterol, low HDL cholesterol, lack of exercise, and possibly high triglycerides and obesity.
You might assume, as this patient did, that even if you have no symptoms, tests are still helpful because they will either reassure you or alert you to conditions you weren’t aware of. But you shouldn’t need a stress test to persuade yourself to improve your diet, give up smoking and take your medication as prescribed. A stress test with normal results can create a false sense of security, which might cause you to relax your healthful habits.
And an abnormal test might cause unnecessary worry and depression. Worse, it can lead to invasive and potentially harmful testing and treatment. You might even find yourself facing the business end of a scalpel with no more chance of preventing a heart attack or improving survival than what could be achieved with medication.
That said, there are a few situations that justify screening for coronary disease for people without symptoms. Those with two or more risk factors who are about to undergo complicated surgery or begin a vigorous exercise program might benefit from stress testing. And screening for those whose jobs affect other people’s safety, such as bus drivers and airline pilots, could save lives.
Lipman reviewed the tests imposed on the accountant but didn’t have the heart to tell him that they were unnecessary, even if the outcome was a clean bill of heart health. And what a bill it was. But he remained convinced that “just knowing” made it all worthwhile.