Sage Journals: Discover world-class research

Abstract

Non-invasive screenings have been widely utilized in the United States and worldwide to provide early identification of cardiovascular disease, allowing for earlier diagnosis and treatment. Screening sonography detects valve disease, cardiac dysfunction, and carotid disease in 5% to 20% of the population. This review discusses the current data regarding cardiovascular screening, the methodologies, and the resources required for performance of screenings. Cardiac and carotid sonography is highly accurate and discovers cardiovascular diseases that impact quality of life and risk of future events. Screenings are performed in a variety of settings and accuracy depends on the quality of personnel performing the non-invasive testing, the equipment utilized, and the personnel interpreting the studies. Despite the potential benefit for disease detection, population screening to detect cardiovascular disease is not widely supported by national organizations due to the theoretical cost of further testing and lack of cost versus benefit data. Additional studies are necessary to compare costs and benefits of non-invasive cardiovascular screening in the community setting.

Keywords

cardiovascular disease screening electrocardiogram

Introduction

Despite advances in clinical cardiology and diagnostic imaging, cardiovascular disease (CVD) is the leading cause of death in the United States.¹ Early diagnosis facilitates treatment of CVD. Unrecognized cardiac and vascular abnormalities can be detected through population-based screening in up to 25% of participants.² Screening for CVD could aid in early identification to reduce morbidity through early intervention.^3,4 This review describes the evidence for utilization of screening, discusses the concerns around community screening programs, and describes technologies performed in community non-invasive cardiovascular screening. Additional studies will be required to weigh the costs versus benefits of cardiovascular screenings in the community.

Screening examinations are defined as an abbreviated examination that briefly evaluates potential abnormalities in an asymptomatic patient.⁵ Screening examinations differ from diagnostic examinations, which are ordered by a physician, require a sign or symptom as an indication for the examination, include comprehensive imaging by a modality, and are reimbursed by the Centers for Medicare & Medicaid Services (CMS).⁶ Only one lifetime screening electrocardiogram and one aortic aneurysm screening are currently reimbursed by CMS, which requires a physician’s order, and performed in a diagnostic setting. The recommendations for or against as well as the potential reimbursement for screening examinations depend on the type of testing provided and imaging equipment used. Health screenings have been utilized internationally to stratify risk and detect significant cardiovascular findings in asymptomatic patients.^7–9 Population screenings have demonstrated sonography as being effective in detecting a variety of CVD with the intent to increase detection of asymptomatic disease and lead to early intervention.¹⁰ For example, cardiac sonography in the community screening populations has detected valve disease¹¹ and poor heart function in 4.1% of patients at risk of heart failure,¹² and carotid sonography has detected 9.6% of patients having ≥ 50% carotid arterial stenosis.¹³

Companies such as Lifeline and Healthfair provide mobile self-referred, self-paid community screenings throughout the United States and suggest that physicians recommend preventive screenings for people at risk.¹⁴ Because the consumer chooses the types of tests to be performed and the testing does not require a physician order and is not reimbursed by insurance, these types of screenings differ from other types of community screenings that target certain populations or are performed with a physician’s referral and are reimbursed.

Overview of the Literature

This review outlines the use of non-invasive cardiovascular testing performed in the community setting to screen for CVD, to include electrocardiogram (ECG), screening cardiac sonography, aortic sonography, screening carotid sonography, and ankle brachial index (ABI).

Use of Electrocardiogram in Screenings

ECG can detect electrical abnormalities such as atrial fibrillation in adults, which can, if undiagnosed, lead to stroke. Undiagnosed atrial fibrillation is present in 1.4% to 1.8% of the population greater than 65 years of age, which increases the risk of stroke.^2,15 Early studies reported the risk of stroke in patients with atrial fibrillation to be 6.7% for ages 50 to 59 years and 36.2% for ages 80 to 89 years.¹⁶ The annual rate of strokes in patients on anticoagulation with atrial fibrillation is 2.0 per 100 patient-years.¹⁷ Asymptomatic atrial fibrillation, known as “silent atrial fibrillation,” has the same outcomes as symptomatic atrial fibrillation.¹⁸ Screenings would be able to detect asymptomatic (silent) and symptomatic atrial fibrillation, thereby allowing for necessary therapeutic treatment to decrease the risk of stroke. Single ECG screenings are recommended¹⁹ and reimbursed by CMS with a physician or provider order in patients with Medicare Part B insurance.²⁰ ECG screening in the adult population has been shown to be cost-effective and is paid for once in the patient’s lifetime.¹⁹

In Europe, the use of ECG screenings in adolescents has demonstrated a decline in sudden cardiac disease in athletes screened for cardiac disease.²¹ In young adults, history alone detects only about half of cardiac abnormalities.²² With the addition of using ECG, sensitivity of cardiac disease is increased to 90% with a specificity of 82.7%.²³ Depending on populations, adding patient history or cardiac sonography to ECG alone can increase sensitivity from 2.5% using a preparticipation sports physical and athlete interpretation criteria to 50%.²¹

Opponents of ECG screening in adolescents cite a false positive rate of 16.9%, with some rates as high as 40%, but guidelines have been revised to minimize the false positive rates.^21,22,24 In 2010, the European Society of Cardiology adopted criteria differentiating normal, defined as ECG changes due to athletic physical peak performance training, from abnormal, defined as pathologic ECG changes.²⁵ Interobserver agreement for ECG using this criterion was demonstrated to be κ = 0.30 to 0.54 (poor to moderate).²⁵ Subsequently, the development of screening-specific interpretation criteria for athlete ECG has decreased false positive rates and increased cost-effectiveness.^26–28 By adding a screening ECG with an incremental cost of $89 per participant, it is estimated to save 2.06 life-years per 1000 participants with a cost-effectiveness ratio of $42 900 per life-year.²⁹

ECG is recognized to have a high negative predictive value, but false negative rates can range from 4% to 5%.²¹ Although mandatory ECG screening has not been adopted in the United States, there is a legal precedent to disqualify athletes from competitive sports, aimed to prevent the risk of death, with physicians adhering to American Heart Association guidelines.³⁰ If mandatory ECG training were translated to the United States, the estimated program costs of athletes to be screened by ECG would be $51 billion to $69 billion dollars over a 20-year program, with 4813 projected saved lives and a cost per life saved being estimated at $10.6 million to $14.4 million per life.³¹ Some have suggested eliminating mandatory ECG screenings but providing the best practice options of screening without the cost of mandating the testing.³²

Cardiac Sonography Screening

Recent population screening in asymptomatic participants detected 10% to 20% new heart failure using low- and high-risk models.³³ Due to trials recommending early diagnosis in heart dysfunction, the SCREEN-HF study integrates echocardiography with a health screening as a mechanism to detect heart failure, save lives, provide economic benefit, and extend work longevity.³⁴ Screening may be appropriate in certain populations such as athletes or those identified with cardiovascular risk.^35,36

A randomized study of 6861 middle-age participants (age range, 30-75 years) undergoing standard 2D and color Doppler imaging in the parasternal and apical views with a 15-year follow-up showed no mortality benefit for stroke or heart attack but did find a mortality benefit in patients who had a family history of heart attack.³⁷ Echocardiographic screening with subsequent medical treatment in childhood cancer survivors demonstrated that screening every 5 to 10 years extends life expectancy, increases quality-adjusted life-years, and reduces complications.^3,38 Cardiac sonography also serves as a secondary diagnostic tool when used in conjunction with ECG screening. For example, when screening patients for hypertrophic cardiomyopathy and Wolff-Parkinson-White ECG abnormalities, 15% of the screened population would require follow-up cardiac sonogram.⁴

Abdominal Aneurysm Screening

Screening for abdominal aortic aneurysm (AAA) of greater than 3 cm in size reduces the 83% mortality rate of asymptomatic undiagnosed AAA rupture.³⁹ The mortality reduction is more pronounced in men older than 65 years with familial and smoking history.⁴⁰ Due to the published efficacy of the benefit of sonographic screening for aortic aneurysm, in 2007, CMS began paying for one-time sonographic screening with a physician referral as a class B recommendation in men ages 65 to 75 years who have ever smoked.^41,42 AAA screening remains cost-effective⁴³ and reduces mortality.^44–46 For aneurysms 3.0 to 4.0 cm in size, cost-effectiveness analysis suggests reimaging every several years as the optimal screening surveillance time frame. Reimaging of AAA is indicated for aneurysms from 4.0 to 4.9 cm in size every 1 to 2 years and every 3 to 6 months for aneurysms 5.0 to 5.4 cm.⁴⁷

Carotid Sonographic Screening

The use of sonography to detect significant carotid artery stenosis (CAS) is well established in the American College of Cardiology/American Heart Association appropriate management guidelines.⁴⁸ The guidelines outline appropriate interventions in symptomatic and asymptomatic populations. Screening for CAS in both populations using sonography aids practitioners in treatment, including more than 250,000 carotid endarterectomies performed annually to reduce downstream risk of stroke and cardiovascular events.⁴⁹ Predicting patient risk is improved with the use of carotid sonographic screening in asymptomatic patients.⁵⁰ The presence of carotid plaque or focal thickening of greater than 50% detected through carotid imaging in asymptomatic low-risk patients has been termed subclinical. Although asymptomatic, this subclinical plaque detected in 34% of patients would reclassify patients into higher risk categories.⁵¹ Prevalence of carotid stenosis varies by population from 5.2% to 7.7% in populations ranging from 50 to 80 years of age.^52,53

Participants with detection of subclinical carotid disease have been demonstrated to have an event rate of 4.2% in an average of 2.7 years of follow up.⁵⁰ Asymptomatic carotid luminal narrowing has been associated with silent brain infarctions, which have a 2-fold increased risk of stroke.⁵⁴ Five-year survival of 96% has been demonstrated in low-risk asymptomatic patients with CAS having carotid endarterectomy to prevent future stroke events.⁵⁵ Carotid sonographic screening in the emergency department with specialist management has been shown to reduce unnecessary admissions to the hospital by 25% to 40%.⁵⁶

Calculated Ankle Brachial Index

Calculated ABI testing has few data evaluating the benefits while comparing possible harm from additional testing.⁵⁷ ABI testing detects pressure-flow-reducing peripheral arterial disease and has a sensitivity of 87.9% for predicting cardiovascular mortality.⁵⁸ Prevalence of peripheral arterial disease in the general population ranges from 3.5% to 6.7%, depending on ethnic background, with higher rates up to 25.3% in patients with diabetes.^53,59,60 Screening for asymptomatic peripheral arterial disease may be especially important in patients with diabetes due to the lack of classic symptoms.⁶¹ Some studies have demonstrated peripheral arterial disease rates of 29% using ABI screening in patients older than 50 years.⁶² As with other disease states, early diagnosis and intervention can aid in slowing the progression to amputation in this population.⁶¹ ABI testing used as a screening tool in conjunction with the Framingham risk score has been demonstrated to improve risk classification.⁶³

Screening Results

A variety of factors impact the results obtained during screening. Obtaining false positive and false negative results is an inherent risk of all screening tests. The sensitivity should be sufficiently high to ensure that significant disease is not missed (high sensitivity with limited false negative results), whereas the specificity must be high enough to minimize the number of false positive results. False positive and false negative rates can be influenced by the definitions of negative, positive, or indeterminate results as well as the population screened. For example, when differentiating normal versus abnormal mitral valve disease, a 90.2% sensitivity and 92.9% specificity using only 2D and color Doppler cardiac could be achieved. In the same study, when distinguishing between more specific abnormalities, the sensitivity drops to 66.7% with false negative results occurring.⁶⁴

Differing rates of positive screenings vary depending on the type of cardiovascular screening tool utilized. The prevalence of heart function abnormalities in screenings ranges from 1% to 14%.⁸ Other studies indicate that only 4% of screenings demonstrate abnormal heart function in asymptomatic patients using cardiac sonography.⁹ Population screening for carotid disease demonstrated a 9% positive detection rate of unilateral or bilateral carotid stenosis equal to or greater than 50% stenosis.¹³ More recent data from screened patients undergoing cardiac surgery demonstrated a 16.3% rate of patients having CAS greater than or equal to 50%.⁶⁵ ABI screening in asymptomatic adult patients has demonstrated a 2% positive rate.⁶⁶

When positive results are obtained on screening studies, additional testing is often required. Utilization of minimal screening technology without confirmatory testing can result in unnecessary chronic medical treatment.⁶⁴ Handheld technology that may not be robust, especially in the hands of nonexperts (uncredentialed or untrained),⁶⁷ can result in false positive or false negative cases. Although few data for the use of handheld ultrasound devices in cardiovascular applications are available, the use of handheld ultrasound devices in breast applications has an 8.3% to 20.8% false positive rate.⁶⁸ When comparing high-end cardiac ultrasound equipment with handheld technology, adequate visualization of basic left ventricular function⁶⁹ (κ = 0.89) can be achieved, but more detailed analysis of valvular function is more challenging with less agreement (κ = 0.55).⁷⁰ False positive results often lead to additional testing. On the other hand, false negative testing results in missed opportunities to intervene early and stop disease progression with additional downstream costs from treatment in advanced disease states.

Overdiagnosis occurs when screening identifies CVD that would not have resulted in a patient’s death if left untreated. Potential harmful effects of overdiagnosis include stress that accompanies diagnosis as well as the mortality and morbidity that accompanies unnecessary procedures. Societal costs also result from lost work time.

Requirements of Facilities Providing a Screening Program

Facilities providing CVD imaging screenings should have appropriate resources to perform the testing that includes a sonographer with cardiovascular credentials obtained from a national credentialing organization, a reading physician with specialty cardiovascular credentials in interpretation, and a program of performance improvement and assessment.⁷¹ Perhaps the most important part of the personnel requirements is the requirement of credentialed staff performing studies. Radiology studies have indicated a significant effect in screening results due to variation in mammography technologists, but more research is required to explore what types of variation affect the results.⁷² National recommendations suggest that personnel performing sonography have, at a minimum, obtained a national credential in the modality in which they are performing the image acquisition.⁷³ Utilization of staff performing the imaging who have limited training can reduce sensitivity of disease to 21% to 33% in cardiac valvular abnormalities requiring Doppler evaluation.⁷⁴ Extending training to include didactic and 3 months of practical training can improve sensitivity in medical students with focused (limited) diagnosis but still results in wide performance variation among staff (correlation variation ranging from 0.29 to 0.93).⁷⁵ Additionally, poorly trained staff performing the imaging creates variability in image interpretation resulting in an interrater agreement between 0.55 and 0.88.⁷⁴

In addition to requiring credentialed staff to perform the screening examinations, it is also important to have cardiologists rather than general physicians perform the interpretations. Cardiologist interpretation of ECG can improve the negative predictive value from 82% to 92% in patients presenting with heart failure.⁷⁶ Cardiologists with training specific to cardiac sonography are also less likely to miss clinically important cardiac sonographic findings when compared with physicians with less training.⁷⁷ Differences in positive predictive value suggested that physicians with less training may also be more likely to overcall abnormalities, resulting in increased false positives and increased downstream testing with the associated increase in cost, stress to the patient, and loss to societal productivity.⁷⁷

Screening Program Accreditation

To ensure standards of organizations providing screening, the American College of Radiology and the Society of Radiologists in Ultrasound provide practice guidelines for the performance of screening ultrasound. The American Institute of Ultrasound in Medicine provides accreditation with specifications relating to nine topics to ensure that organizations adhere to the standards set forth by the American College of Radiology.⁷⁸ These standards include a requirement of all sonographers being credentialed and physicians’ interpretations performed by a physician who has training and experience in the specific area of sonography. The American Institute of Ultrasound in Medicine recommends that requests for screening require a physician or other appropriately licensed health care provider order, thereby limiting self-referrals found in community health screenings. The Commission for the Accreditation of Medical Screening Services provides an alternate accreditation for screening services to the general public. This accreditation also includes requirements relating to technical, professional, equipment, and reporting specifications.⁷¹ The Intersocietal Accreditation Commission accredits vascular screening examinations and states that “standards of vascular testing similar to diagnostic examinations are nonetheless necessary to ensure high quality patient care and to promote health.”⁷¹ This statement aids in highlighting the importance of high-quality imaging regardless of whether the imaging is for screening or diagnostic purposes.

Quality Assurance for Screening Patients

Standardized structured reporting, including the date of the screening examination; adequate description of the test performed; preliminary, positive, negative, and pertinent findings; reasons for incomplete examination; the interpreting physician’s typed name and date; and the performing technologist’s name, is required for accreditation.⁷¹ Reproducible and accurate imaging can be obtained with standardized protocols and high-quality techniques. The interpretation criterion recommends values for carotid sonograms: normal, abnormal, and abnormal with significant findings. ABI testing and AAA screening recommend interpretation values of normal, abnormal, or nondiagnostic. Quality assurance helps to ensure ongoing evaluation of quality testing.⁷¹ Evaluating screening results and comparing accuracy of additional diagnostic testing are important for ongoing improvement in testing.

Equipment Considerations When Performing a Screening Examination

The goal of screening is to provide detection of cardiac, venous, arterial, and electrocardiographic disease through a variety of cardiovascular testing including sonography, electrocardiography, and extremity blood pressure testing. Mobile compact ultrasound equipment now provides the ability to obtain high-quality diagnostic imaging and quantification in the remote setting. This should be differentiated from handheld point-of-care ultrasound equipment that provides imaging without diagnostic quantification, video loop storage, or reporting capabilities.⁷⁹ Handheld ultrasound devices have been utilized to perform focused imaging to detect cardiac abnormalities such as rheumatic heart disease,^80–83 inferior vena cava size,⁸⁴ pericardial effusion,^69,75 left ventricular dimensions,^85–88 and global function evaluation.^89,90 Detecting aortic stenosis, mitral regurgitation, tricuspid regurgitation,⁹¹ pulmonary hypertension,⁹² right ventricular function, and left ventricular regional wall motion abnormalities has been demonstrated to be unreliable with handheld ultrasound devices due to poor correlation with full-size diagnostic imaging equipment.⁷⁵ Furthermore, visualization of the abdominal aorta or pulmonary valve may be adequately assessed only 50% of the time using a handheld ultrasound device.⁷⁵ Adequate cardiovascular health screening services must utilize high-quality imaging, quantification, and reporting equipment to aid in providing accurate results and reduce the possibility of false positive or false negative results.⁶⁴

Concerns Relating to Community Screenings

The advocacy group Public Citizen has raised concerns relating to community screenings. A key topic in the national discussion relates to screening patients who may be asymptomatic. Screening for initial evaluation of heart function in asymptomatic patients is considered inappropriate under the 2011 Appropriate Use Criteria published and approved by 10 national organizations including the American Society of Echocardiography and the American College of Cardiology.⁹³ To aid in reducing inappropriate testing, the American Society of Echocardiography has partnered with the American Board of Internal Medicine Foundation’s Choosing Wisely^® campaign to educate consumers to reduce unnecessary diagnostic testing.

The US Preventive Services Task Force released a statement against carotid sonographic screening in the asymptomatic general adult population due to the possibility of false positive tests resulting in additional unnecessary testing.⁹⁴ This decision was made because the literature demonstrates that benefits of screening do not outweigh the possible harms of additional invasive testing. To date, there is no published literature demonstrating harm caused by cardiovascular community screening as a result of additional invasive testing. Further research is warranted to evaluate possible harms due to additional testing after screening.

Symptomatic patients often seek medical care resulting in a complete history and physical examination that may identify risk factors and result in diagnostic testing. Asymptomatic patients most often do not seek medical care that could provide an important clinical assessment and history. It is unknown if participants who seek community screenings have symptoms or are seeking the results for preventive lifestyle modifications. Community screenings often do not provide a complete physical assessment, which some assert could detect disease without the need for screenings, including imaging.

Summary of Screening Recommendations

Despite the demonstrated benefits of screening, implementation in the asymptomatic population has been limited due to the theoretical cost of possible subsequent unnecessary downstream testing and avoidable complications. As a result, Medicare reimbursement for screenings in asymptomatic patients has been limited. It is unfortunate that asymptomatic patients with unrecognized, silent, or subclinical disease have been shown to have the same disease progression as those with symptoms.¹⁸ Screenings may be able to detect disease and appropriately risk stratify patients who might need additional treatment or modification of prevention strategies.

Cost-effective simulations show that in targeted screening, 19.2% of high-risk individuals would have cardiovascular disease identified, with 4.1 people needing to be screened to detect disease in 1 person.⁹⁵ High-risk populations may benefit more from screenings. Targeting certain ethnic groups may be more cost-effective and could reduce ethnic health inequities.⁹⁵ Some data suggest that variable willingness to pay may justify doing screenings, especially in high-risk groups.⁹⁶

Synthesis of Screening

Despite cardiac sonography in community screening populations having detected a variety of CVD, widespread screening has been limited due to the national stance on screenings and the lack of CMS reimbursement for all cardiovascular imaging. ECG and AAA screening have been demonstrated to be cost-effective and are reimbursed by CMS. Due to the impact of decreasing risk of future events, carotid and cardiac sonographic screenings have not been approved for reimbursement due to the lack of sufficient data that defines the cost and harm versus benefit. Although echocardiography screening detects asymptomatic heart failure and vascular disease with demonstrated improvements in quality-adjusted life-years, the yield is different depending on the risk associated with the population. Carotid artery screening detecting stenosis reduces downstream risk of cardiovascular events, but prevalence in asymptomatic patients is low, resulting in a large number of required screens to make a significant difference. ABI testing to detect peripheral arterial disease predicts mortality but, again, the prevalence is low unless higher risk populations are screened. National recommendations suggest sonographer and physician credentialing with facility accreditation to improve accuracy of community screenings. Despite data reporting benefits in both symptomatic and asymptomatic populations, national organizations including the American Society of Echocardiography and the American College of Cardiology do not support screening in asymptomatic patients without a physician order.⁹³

Summary

Screening for CVD has been demonstrated to be effective at detecting disease through a variety of non-invasive testing methods. Early detection of CVD through the use of community health screenings may be an effective tool for detecting subclinical disease and improving the health status of patients through proactive follow-up. Utilization of credentialed personnel and high-end equipment with adherence to national standards of performance will optimize accuracy while minimizing false positive and false negative results. Few published data are available regarding who attends self-referred community cardiovascular screenings that are paid for by the consumer. Additional studies are required to provide data to demonstrate the cost and harm versus benefit of non-invasive cardiovascular screening in the community setting.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Centers for Disease Control and Prevention. Underlying cause of death 1999-2013 [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; 2015 [cited 2015 Feb 3]. Available from: CDC WONDER Online Database.

van Mourik

Bertens

Cramer

Lammers

Reitsma

Moons

Hoes

Rutten

FH.

Unrecognized heart failure and chronic obstructive pulmonary disease (COPD) in frail elderly detected through a near-home targeted screening strategy. J Am Board Fam Med. 2014 Nov-Dec;27(6):811–21.

Yeh

Nohria

Diller

Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors: a model-based estimation of the clinical and economic effects. Ann Intern Med. 2014 May 20;160(10):661–71.

Riding

Sharma

Salah

Khalil

Carré

George

Hamilton

Chalabi

Whyte

Wilson

MG.

Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia. Eur J Prev Cardiol. 2015 Feb;22(2):263–70.

What’s the difference between a screening mammogram and a diagnostic mammogram? [Internet]. Atlanta (GA): American Cancer Society; 2014 [cited 2015 Apr 28]. Available from: http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/mammogramsandotherbreastimagingprocedures/mammograms-and-other-breast-imaging-procedures-types-of-mammograms

Abram

Screening and diagnostic tests [Internet]. New York: WebMD; 2013 [cited 2015 Apr 29]. Available from: http://emedicine.medscape.com/article/773832-overview

Folyovich

Bakos

Kántor

Hertelendy

Horváth

Zsiga

Lakatos

Vadasdi

Stroke prevention—a population screening day in district XII of Budapest. Ideggyogy Sz. 2012 Mar 30;65(3–4):101–5.

Atherton

JJ.

Screening for left ventricular systolic dysfunction: is imaging a solution?

JACC Cardiovasc Imaging. 2010 Apr;3(4):421–8.

Coller

Campbell

Krum

Prior

DL.

Early identification of asymptomatic subjects at increased risk of heart failure and cardiovascular events: progress and future directions. Heart Lung Circ. 2013 Mar;22(3):171–8.

10.

Drezner

Berger

Campbell

Current controversies in the cardiovascular screening of athletes. Curr Sports Med Rep. 2010 Mar–Apr;9(2):86–92.

11.

Saxena

Zuhlke

Wilson

Echocardiographic screening for rheumatic heart disease: issues for the cardiology community. Glob Heart. 2013 Sep;8(3):197–202.

12.

Murtagh

Dawkins

O’Connell

Badabhagni

Patel

Tallon

O’Hanlon

Ledwidge

McDonald

KM.

Screening to prevent heart failure (STOP-HF): expanding the focus beyond asymptomatic left ventricular systolic dysfunction. Eur J Heart Fail. 2012 May;14(5):480–6.

13.

Jacobowitz

Rockman

Gagne

Adelman

Lamparello

Landis

Riles

TS.

A model for predicting occult carotid artery stenosis: screening is justified in a selected population. J Vasc Surg. 2003 Oct;38(4):705–9.

14.

9 out of 10 cardiovascular doctors support preventive health screenings for people at risk [Internet]. Cleveland (OH): Life Line Screening; 2014 [cited 2015 Mar 15]. Available from: http://www.lifelinescreening.com/What-We-Do/Physician-Study

15.

Quinn

Gladstone

Screening for undiagnosed atrial fibrillation in the community. Curr Opin Cardiol. 2014 Jan;29(1):28–35.

16.

Wolf

Abbott

Kannel

WB.

Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987 Sep;147(9):1561–4.

17.

Hohnloser

Pajitnev

Pogue

Healey

Pfeffer

Yusuf

Connolly

; ACTIVE W Investigators. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. J Am Coll Cardiol. 2007 Nov 27;50(22):2156–61.

18.

Boriani

Pettorelli

Atrial fibrillation burden and atrial fibrillation type: clinical significance and impact on the risk of stroke and decision making for long-term anticoagulation. Vascul Pharmacol. 2016 Aug;83:26–35.

19.

Moyer

VA.

Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Oct 2;157(7):512–8.

20.

US Centers for Medicare & Medicaid Services. Is my test, item, or service covered? [Internet]. Baltimore (MD): US Centers for Medicare & Medicaid Services; 2015 [cited 2015 Apr 29]. Available from: http://www.medicare.gov/coverage/mammograms.html

21.

Lawless

Best

TM.

Electrocardiograms in athletes: interpretation and diagnostic accuracy. Med Sci Sports Exerc. 2008 May;40(5):787–98.

22.

Baggish

Hutter

Jr Wang

Yared

Weiner

Kupperman

Picard

Wood

MJ.

Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study. Ann Intern Med. 2010 Mar 2;152(5):269–75.

23.

Harmon

Zigman

Drezner

JA.

The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol. 2015 May–Jun;48(3):329–38.

24.

Fudge

Harmon

Owens

Prutkin

Salerno

Asif

Haruta

Pelto

Rao

Toresdahl

Drezner

JA.

Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG. Br J Sports Med. 2014 Aug;48(15):1172–8.

25.

Brosnan

La Gerche

Kumar

Kalman

Prior

Modest agreement in ECG interpretation limits the application of ECG screening in young athletes. Heart rhythm. 2015 Jan;12(1):130–6.

26.

Asif

Prutkin

JM.

Modern standards of ECG interpretation in young athletes: yield and effectiveness. J Electrocardiol. 2015 May–Jun;48(3):292–7.

27.

Corrado

Pelliccia

Heidbuchel

Sharma

Link

Basso

Biffi

Buja

Delise

Gussac

Anastasakis

Borjesson

Bjørnstad

Carrè

Deligiannis

Dugmore

Fagard

Hoogsteen

Mellwig

Panhuyzen-Goedkoop

Solberg

Vanhees

Drezner

Estes

3rd Iliceto

Maron

Peidro

Schwartz

Stein

Thiene

Zeppilli

McKenna

; Section of Sports Cardiology, European Association of Cardiovascular Prevention and Rehabilitation. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J. 2010 Jan;31(2):243–59.

28.

Uberoi

Stein

Perez

Freeman

Wheeler

Dewey

Peidro

Hadley

Drezner

Sharma

Pelliccia

Corrado

Niebauer

Estes

3rd Ashley

Froelicher

Interpretation of the electrocardiogram of young athletes. Circulation. 2011 Aug 9;124(6):746–57.

29.

Wheeler

Heidenreich

Froelicher

Hlatky

Ashley

EA.

Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010 Mar 2;152(5):276–86.

30.

Paterick

Fletcher

Maron

BJ.

Medical and legal issues in the cardiovascular evaluation of competitive athletes. JAMA. 2005 Dec 21;294(23):3011–8.

31.

Halkin

Steinvil

Rosso

Adler

Rozovski

Viskin

Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost?

J Am Coll Cardiol. 2012 Dec 4;60(22):2271–6.

32.

Borjesson

Drezner

Cardiac screening: time to move forward!

Br J Sports Med. 2012 Nov;46 Suppl 1:i4–6.

33.

Yang

Wang

Nolan

Negishi

Okin

Marwick

TH.

Community screening for nonischemic cardiomyopathy in asymptomatic subjects ≥65 years with stage B heart failure. Am J Cardiol. 2016 Jun 15;117(12):1959–65.

34.

Boffa

McGrady

Reid

Shiel

Wolfe

Liew

Campbell

Stewart

Krum

SCReening Evaluation of the Evolution of New Heart Failure Study (SCREEN-HF): early detection of chronic heart failure in the workplace. Aust Health Rev. 2017 May;41(2):121-6.

35.

Greenland

Alpert

Beller

Benjamin

Budoff

Fayad

Foster

Hlatky

Hodgson

Kushner

Lauer

Shaw

Smith

Jr Taylor

Weintraub

Wenger

Jacobs

; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2010 Dec 21;122(25):e584–636.

36.

Wyman

Chiu

Rahko

PS.

The 5-minute screening echocardiogram for athletes. J Am Soc Echocardiogr. 2008 Jul;21(7):786–8.

37.

Lindekleiv

Løchen

Mathiesen

Njølstad

Wilsgaard

Schirmer

Echocardiographic screening of the general population and long-term survival: a randomized clinical study. JAMA Intern Med. 2013 Sep 23;173(17):1592–8.

38.

Wong

Bhatia

Landier

Francisco

Leisenring

Hudson

Armstrong

Mertens

Stovall

Robison

Lyman

Lipshultz

Armenian

SH.

Cost-effectiveness of the children’s oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure. Ann Intern Med. 2014 May 20;160(10):672–83.

39.

Guirguis-Blake

Beil

Senger

Whitlock

EP.

Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014 Mar 4;160(5):321–9.

40.

Hye

Smith

Wong

Vansomphone

Scott

Kanter

MH.

Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program. J Vasc Surg. 2014 Jun;59(6):1535–42.

41.

Implementation of a one-time only ultrasound screening for abdominal aortic aneurysms (AAA), resulting from a referral from an initial preventive physical examination [Internet]. Chicago (IL): American Medical Association; 2006 [cited 2014 Jul 9]. Available from: http://www.uspreventiveservicestaskforce.org/uspstf14/abdoman/abdomanfinalrs.html

42.

LeFevre

ML.

Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Aug 19;161(4):281–90.

43.

Glover

Kim

Sweeting

Thompson

Buxton

MJ.

Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. Br J Surg. 2014 Jul;101(8):976–82.

44.

Svensjo

Bjorck

Wanhainen

Update on screening for abdominal aortic aneurysm: a topical review. Eur J Vasc Endovasc Surg. 2014 Dec;48(6):659–67.

45.

Svensjo

Mani

Bjorck

Lundkvist

Wanhainen

Screening for abdominal aortic aneurysm in 65-year-old men remains cost-effective with contemporary epidemiology and management. Eur J Vasc Endovasc Surg. 2014 Apr;47(4):357–65.

46.

Nguyen

Hill

Thomson

van Rij

AM.

Evaluation of the accuracy of aorta scan BVI 9600 in screening for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2014 Aug;48(2):147–52.

47.

Thompson

Brown

Sweeting

Bown

Kim

Glover

Buxton

Powell

JT.

Systematic review and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance intervals and their cost-effectiveness. Health Technol Assess. 2013 Sep;17(41):1–118.

48.

Brott

Halperin

Abbara

Bacharach

Barr

Bush

Cates

Creager

Fowler

Friday

Hertzberg

McIff

Moore

Panagos

Riles

Rosenwasser

Taylor

Jacobs

Smith

Jr Anderson

Adams

Albert

Buller

Creager

Ettinger

Guyton

Halperin

Hochman

Hunt

Krumholz

Kushner

Lytle

Nishimura

Ohman

Page

Riegel

Stevenson

Tarkington

Yancy

CW.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76–123.

49.

Skerritt

Block

Pearson

Young

KC.

Carotid endarterectomy and carotid artery stenting utilization trends over time. BMC Neurol. 2012 Mar 29;12:17.

50.

Baber

Mehran

Sartori

Schoos

Sillesen

Muntendam

Garcia

Gregson

Pocock

Falk

Fuster

Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study. J Am Coll Cardiol. 2015 Mar 24;65(11):1065–74.

51.

Lester

Eleid

Khandheria

Hurst

RT.

Carotid intima-media thickness and coronary artery calcium score as indications of subclinical atherosclerosis. Mayo Clin Proc. 2009 Mar;84(3):229–33.

52.

Kaul

Alladi

Mridula

Bandaru

Umamashesh

Anjanikumar

Lalitha

Chandrasekhar

Prevalence and risk factors of asymptomatic carotid artery stenosis in Indian population: an 8-year follow-up study. Neurol India. 2017 Mar-Apr;65(2):279–85.

53.

Kim

Jeon

Cho

Kong

Jung

Park

Cho

Kim

Shin

Ahn

Cho

Kim

Lee

Hur

Choi

Choe

Hong

KC.

Prevalence and characteristics of major vascular diseases of elderly men in the Incheon area. J Korean Surg Soc. 2010;78(5):305–13.

54.

Baradaran

Gialdini

Mtui

Askin

Kamel

Gupta

Silent brain infarction in patients with asymptomatic carotid artery atherosclerotic disease. Stroke. 2016 May;47(5):1368–70.

55.

Wallaert

Cronenwett

Bertges

Schanzer

Nolan

De Martino

Eldrup-Jorgensen

Goodney

; Vascular Study Group of New England. Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival. J Vasc Surg. 2013 Jul;58(1):112–8.

56.

Gulli

Peron

Ricci

Formaglio

Micheletti

Tomelleri

Moretto

Yield of ultra-rapid carotid ultrasound and stroke specialist assessment in patients with TIA and minor stroke: an Italian TIA service audit. Neurol Sci. 2014 Dec;35(12):1969–75.

57.

Moyer

VA.

Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle-brachial index in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Sep 3;159(5):342–8.

58.

Doobay

Anand

SS.

Sensitivity and specificity of the ankle-brachial index to predict future cardiovascular outcomes: a systematic review. Arterioscler Thromb Vasc Biol. 2005 Jul;25(7):1463–9.

59.

Vitalis

Lip

Kay

Vohra

Shantsila

Ethnic differences in the prevalence of peripheral arterial disease: a systematic review and meta-analysis. Expert Rev Cardiovasc Ther. 2017 Apr;15(4):327–38.

60.

Cho

Park

Jeon

Kim

Kong

Jung

Cho

Hong

Shin

SH.

Vascular disease prevalence and risk factors in a screened Korean male population. Ann Vasc Surg. 2015 Feb;29(2):215–21.

61.

Sheehan

Peripheral arterial disease in people with diabetes: consensus statement recommends screening. Clin Diabetes. 2004;22(4):179–80.

62.

Dormandy

Rutherford

RB.

Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000 Jan;31(1 Pt 2):S1–S296.

63.

Ferket

van Kempen

Hunink

Agarwal

Kavousi

Franco

Steyerberg

Max

Fleischmann

KE.

Predictive value of updating Framingham risk scores with novel risk markers in the U.S. general population. PloS One. 2014;9(2):e88312.

64.

Beaton

Aliku

Okello

Lubega

McCarter

Lwabi

Sable

The utility of handheld echocardiography for early diagnosis of rheumatic heart disease. J Am Soc Echocardiogr. 2014 Jan;27(1):42–9.

65.

Chun

Tsai

Tam

Prema

Chen

Patel

KK.

Screening carotid artery duplex in patients undergoing cardiac surgery. Ann Vasc Surg. 2014 Jul;28(5):1178–85.

66.

Taylor-Piliae

Fair

Varady

Hlatky

Norton

Iribarren

Fortmann

SP.

Ankle brachial index screening in asymptomatic older adults. Am Heart J. 2011 May;161(5):979–85.

67.

Galderisi

Santoro

Versiero

Lomoriello

Esposito

Raia

Farina

Schiattarella

Bonito

Olibet

de Simone

Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study. Cardiovasc Ultrasound. 2010;8(1):51.

68.

Chang

Moon

Cho

Park

Kim

SJ.

Breast cancers initially detected by hand-held ultrasound: detection performance of radiologists using automated breast ultrasound data. Acta Radiol. 2011 Feb 1;52(1):8–14.

69.

Prinz

Voigt

JU.

Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography. J Am Soc Echocardiogr. 2011 Feb;24(2):111–6.

70.

Testuz

Müller

Keller

Meyer

Stampfli

Sekoranja

Vuille

Burri

Diagnostic accuracy of pocket-size handheld echocardiographs used by cardiologists in the acute care setting. Eur Heart J Cardiovasc Imaging. 2013 Jan;14(1):38–42.

71.

Commission for the Accreditation of Medical Screening Services. Standards for accreditation in vascular screening examinations [Internet]. Ellicott City (MD): Intersocietal Accreditation Commission; 2010. Available from: https://www.intersocietal.org/cams/pdfs/2010_CAMS_Standards.pdf

72.

Henderson

Benefield

Marsh

Schroeder

Durham

Yankaskas

Bowling

JM.

The influence of mammographic technologists on radiologists’ ability to interpret screening mammograms in community practice. Acad Radiol. 2015 Mar;22(3):278–89.

73.

Bierig

Ehler

Knoll

Waggoner

AD.

American Society of Echocardiography minimum standards for the cardiac sonographer: a position paper. J Am Soc Echocardiogr. 2006 May;19(5):471–4.

74.

Shmueli

Burstein

Sagy

Perry

Ilia

Henkin

Shafat

Liel-Cohen

Kobal

SL.

Briefly trained medical students can effectively identify rheumatic mitral valve injury using a hand-carried ultrasound. Echocardiography. 2013 Jul;30(6):621–6.

75.

Mjølstad

Andersen

Dalen

Graven

Skjetne

Kleinau

Haugen

BO.

Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents. Eur Heart J Cardiovasc Imaging. 2013 Dec;14(12):1195–202.

76.

Senior

Galasko

Cost-effective strategies to screen for left ventricular systolic dysfunction in the community—a concept. Congest Heart Fail. 2005 Jul–Aug;11(4):194–8, 211.

77.

DeCara

Lang

Koch

Bala

Penzotti

Spencer

KT.

The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr. 2003 Jun;4(2):141–7.

78.

American Institute of Ultrasound in Medicine. Standards and guidelines for the accreditation of ultrasound practices. Laurel (MD): American Institute of Ultrasound in Medicine; 2014.

79.

GE Healthcare. Vscan portfolio [Internet]. Chicago (IL): GE Healthcare; 2015. Available from: http://www3.gehealthcare.com/en/products/categories/ultrasound/vscan_portfolio

80.

Mirabel

Bacquelin

Tafflet

Robillard

Huon

Corsenac

de Frémicourt

Narayanan

Meunier

Noël

Hagège

Rouchon

Jouven

Marijon

. Screening for rheumatic heart disease: evaluation of a focused cardiac ultrasound approach. Circ Cardiovasc Imaging. 2015 Jan;8(1).

81.

Beaton

Aliku

Dean

Gaur

Weinberg

Godown

Lwabi

Mirembe

Okello

Reese

Shrestha-Astudillo

Bradley-Hewitt

Scheel

Webb

McCarter

Ensing

Sable

The utility of handheld echocardiography for early rheumatic heart disease diagnosis: a field study. Eur Heart J Cardiovasc Imaging. 2015 May;16(5):475–82.

82.

Godown

Beaton

Sable

Mirembe

Sanya

Aliku

Lwabi

Webb

Ensing

GJ.

Handheld echocardiography versus auscultation for detection of rheumatic heart disease. Pediatrics. 2015 Apr;135(4):e939–44.

83.

Sable

Ensing

Webb

Scheel

Aliku

Lwabi

Godown

Beaton

Simplified rheumatic heart disease screening criteria for handheld echocardiography. J Am Soc Echocardiogr. 2015 Apr;28(4):463–9.

84.

Dalen

Gundersen

Skjetne

Haug

Kleinau

Norekval

Graven

Feasibility and reliability of pocket-size ultrasound examinations of the pleural cavities and vena cava inferior performed by nurses in an outpatient heart failure clinic. Eur J Cardiovasc Nurs. 2015 Aug;14(4):286–93.

85.

Stoica

Heller

Bella

JN.

Point-of-care screening for left ventricular hypertrophy and concentric geometry using hand-held cardiac ultrasound in hypertensive patients. Am J Cardiovasc Dis. 2011;1(2):119–25.

86.

Coletta

De Marchis

Lenoli

Rosato

Renzi

Sestili

Romano

Infusino

Ricci

Ceci

Reliability of cardiac dimensions and valvular regurgitation assessment by sonographers using hand-carried ultrasound devices. Eur J Echocardiogr. 2006 Aug;7(4):275–83.

87.

Senior

Galasko

Hickman

Jeetley

Lahiri

Community screening for left ventricular hypertrophy in patients with hypertension using hand-held echocardiography. J Am Soc Echocardiogr. 2004 Jan;17(1):56–61.

88.

Vourvouri

Poldermans

Schinkel

Koroleva

Sozzi

Parharidis

Bax

Roelandt

JR.

Left ventricular hypertrophy screening using a hand-held ultrasound device. Eur Heart J. 2002 Oct;23(19):1516–21.

89.

Prinz

Dohrmann

van Buuren

Bitter

Bogunovic

Horstkotte

Faber

The importance of training in echocardiography: a validation study using pocket echocardiography. J Cardiovasc Med (Hagerstown). 2012 Nov;13(11):700–7.

90.

Xie

Chamoun

McCulloch

Tsiouris

Birnbaum

Ahmad

Rapid screening of cardiac patients with a miniaturized hand-held ultrasound imager—comparisons with physical examination and conventional two-dimensional echocardiography. Clin Cardiol. 2004 Apr;27(4):241–5.

91.

Quiles

García-Fernández

Almeida

Pérez-David

Bermejo

Moreno

Avanzas

Portable spectral Doppler echocardiographic device: overcoming limitations. Heart. 2003 Sep;89(9):1014–8.

92.

Vignon

Frank

Lesage

Mücke

François

Normand

Bonnivard

Clavel

Gastinne

Hand-held echocardiography with Doppler capability for the assessment of critically-ill patients: is it reliable?

Intensive Care Med. 2004 Apr;30(4):718–23.

93.

Douglas

Garcia

Haines

Lai

Manning

Patel

Picard

Polk

Ragosta

Parker Ward

Weiner

RB.

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011 Mar;24(3):229–67.

94.

LeFevre

ML.

Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Sep 2;161(5):356–62.

95.

Baker

Mitchell

Lawson

Pell

Ethnic differences in the cost-effectiveness of targeted and mass screening for high cardiovascular risk in the UK: cross-sectional study. Heart. 2013 Dec;99(23):1766–71.

96.

Aljutaili

Becker

Witt

Holle

Leidl

Block

Brachmann

Silber

Bestehorn

Stollenwerk

Should health insurers target prevention of cardiovascular disease? A cost-effectiveness analysis of an individualised programme in Germany based on routine data. BMC Health Serv Res. 2014 Jun 17;14:263.

Cardiovascular Ultrasound Combined With Non-invasive Screening for the Detection of Undiagnosed Cardiovascular Disease: A Literature Review

Abstract

Keywords

Introduction

Overview of the Literature

Use of Electrocardiogram in Screenings

Cardiac Sonography Screening

Abdominal Aneurysm Screening

Carotid Sonographic Screening

Calculated Ankle Brachial Index

Screening Results

Requirements of Facilities Providing a Screening Program

Screening Program Accreditation

Quality Assurance for Screening Patients

Equipment Considerations When Performing a Screening Examination

Concerns Relating to Community Screenings

Summary of Screening Recommendations

Synthesis of Screening

Summary

Footnotes

Declaration of Conflicting Interests

Funding

References