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August 27, 2014

Testing for “Silent” Coronary Heart Disease

JAMA. 2014;312(8):858. doi:10.1001/jama.2014.9191

Some people who have coronary heart disease have no symptoms of the disease.

Why Test for “Silent” Coronary Heart Disease?

Heart disease is the leading cause of death in the United States. Coronary heart disease refers to heart disease resulting from the buildup of plaque (collection of cholesterol, calcium, and other materials) in the coronary arteries (blood vessels) that supply blood to the heart.

Common symptoms of coronary heart disease include chest pain and trouble breathing, especially with activity. Many people who have coronary heart disease do not have any symptoms and therefore do not know they have problems with their heart. As a result, they do not take the proper medications that could help prevent a heart attack, stroke, or death. In these people without symptoms, testing for coronary heart disease may still be useful.

Who Should Be Tested?

As a general rule, in people without any symptoms, only those with a high risk of having heart disease should be tested for it. These people are said to have high cardiovascular risk. Knowing which people are in this high-risk category is important. Several risk assessment tools are available to help doctors decide who should get tested.

Examples of some risk assessment tools include the Framingham Risk Score, the Pooled Cohort Equations, and the Systematic Coronary Risk Evaluation (SCORE). These tools take into account risk factors for heart disease such as older age, smoking, high blood pressure, being overweight or obese, diabetes, high cholesterol, and a family history of heart disease. They also help doctors decide who should be treated with certain medications, such as statins for high cholesterol.

Types of Tests

In people without symptoms, basic testing for coronary heart disease involves checking for the above risk factors as part of a general medical examination.

But there are also several other kinds of tests available that have not been studied enough to say that they are useful for everyone. Your doctor can guide you on whether these tests may or may not be right for you. They include

  • Blood tests: High levels of high-sensitivity C-reactive protein or homocysteine in the blood may suggest a higher cardiovascular risk in a select group of people.

  • Electrocardiogram: An electrocardiogram (ECG) shows the electrical activity of the heart. For people with no symptoms, an exercise ECG (treadmill stress test) is generally not recommended to screen for coronary heart disease.

  • Imaging tests: Imaging tests look for signs of plaque buildup in the arteries. Some types of imaging tests used for screening for heart disease are ultrasound and computed tomography (CT) scan.

Ultrasound can be used to look at the heart as a whole as well as larger arteries in the body (such as the carotid artery in the neck and the aorta in the abdomen). But the small arteries of the heart, which are the ones that cause heart attacks when they become blocked, cannot be seen by ultrasound. To see these smaller arteries, doctors sometimes recommend a coronary CT scan that looks specifically at the heart arteries. This type of CT scan can estimate the amount of plaque buildup in the arteries of the heart and calculate a coronary artery calcium score. This score can be helpful in predicting cardiovascular risk in some people, as described in the Diagnostic Test Interpretation article in the August 27, 2014, issue of JAMA.

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Article Information

Source: Wallace ML et al. Screening strategies for cardiovascular disease in asymptomatic adults. Prim Care. 2014;41(2):371-397.

Topic: Cardiovascular Disease