Harvard Men's Health Watch

High-tech heart tests and procedures you may not need-and why

Having diagnostic tests for your heart 'just in case' may not help you live longer or feel better, and might cause harm.

One in three American men has some form of cardiovascular disease, according to the American Heart Association. It is no surprise, then, that many men ask their doctors to run extra tests to see how healthy their hearts are. Isn't it smart to "check under the hood" from time to time for hidden danger, such as a blocked coronary artery?

Not always. Unless you have symptoms or risk factors for heart disease, testing may not offer any benefit—and comes with costs and potential risks. "You can't make someone who is feeling fine feel better," says Dr. Thomas Lee, co-editor of the Harvard Heart Letter, "and there is no evidence—for the vast majority of people who are feeling fine—that we're going to make them live longer by doing tests. Then why do them?"

High-tech cardiac imaging

To help address this issue, the American College of Cardiology (ACC) recently released a list of "commonly used but not always necessary tests and procedures." The ACC focused on several kinds of high-tech heart imaging procedures, along with echocardiography and unnecessary stent placement.

Stress cardiac imaging tests capture images of your heart when it's forced to work harder. The stress may take the form of vigorous physical exercise, such as fast walking on a treadmill, or a drug that makes your heart beat faster.

"These tests are meant to detect subtle coronary artery disease that may not be seen or detected in a rest study or to investigate the reason for the symptoms," says Dr. William Zoghbi, director of the Cardiovascular Imaging Institute at The Methodist Hospital in Houston, and current president of the ACC.

Advanced noninvasive imaging tests , such as CT angiography and magnetic resonance imaging (MRI) angiography, create sharp pictures of the moving heart and the coronary arteries feeding it. A coronary artery calcium-scoring scan uses information from a CT to measure the extent of calcium-rich plaques in the coronary arteries.

Unnecessary cardiac imaging

The ACC recommendations highlight several scenarios in which high-tech heart imaging is unlikely to reveal anything that will change treatment in a beneficial way.

Routine risk assessments: The ACC recommends that stress cardiac imaging not be part of a routine or initial assessment of a person's risk for heart disease if that person has no symptoms of heart problems, such as shortness of breath or chest discomfort. The tests are also inappropriate for people lacking key risk factors for heart disease, such as high cholesterol, high blood pressure, diabetes, history of smoking, and a family history of heart disease.

Routine follow up for heart disease. The ACC recommendations also state that stress cardiac imaging is usually not appropriate for routine follow-up in people whose heart disease is stable or who have no symptoms. This includes those previously treated for coronary artery disease with bypass surgery or stents but with no new symptoms or any change in symptoms.

Clearing people for noncardiac surgery. High-tech heart tests should not be performed routinely to clear people for low-risk noncardiac surgery, meaning procedures, such as cataract removal, that are unlikely to stress the cardiovascular system.

Unnecessary echocardiography. Doctors may use echocardiography to check on leaky valves or valves that don't open completely. According to the ACC, people with mild, stable valve disease, and who have no symptoms, benefit little from routine follow-up with echocardiography.

Unnecessary stents for heart attacks. Another ACC recommendation concerns angioplasty, a common procedure for opening narrowed or clogged arteries. During angioplasty, an expandable metal mesh tube (stent) can be installed at the blockage to prop open the artery and restore blood flow to the heart. This is the preferred treatment during an acute heart attack. But the ACC cautions doctors not to place extra stents in coronary arteries that are not related to the person's heart attack—as long as the person is otherwise stable.

The pros and cons of testing

When people undergo unnecessary tests, uncertain benefits may come with some real costs and risks:

Radiation exposure: Some imaging tests expose you to small but not inconsequential amounts of radiation—especially CT scans. Guidelines have been set for the lifetime exposure to such radiation. Why not bank it for times when you really need a test?

False alarms: With every test, there is a chance of "false positive" results. This means the test shows your heart is functioning abnormally when actually everything is fine. False positives lead to more testing and, potentially, unneeded treatment.

Cost: In an era when health-care costs are increasingly being shifted to consumers and their employers, diagnostic tests can hit you in the wallet. The total cost of unnecessary tests is borne by all of us.

Wasted time: The total time that you spend arranging, undergoing, and following up tests adds up. You spend part of that time worrying about the results of the test, too.

A joint decision

The ACC recommendations are meant to encourage more informed decision-making by you and your doctor. "That conversation should be about the goal of the test or procedure," Dr. Lee says. "It is reasonable for patients to ask whether a test is intended to make you feel better or live longer."

For a person with symptoms, diagnosing and treating underlying heart disease can achieve both goals. But research shows that testing a person without symptoms or risk factors for disease is unlikely to uncover a problem. Since the person already feels good, he won't feel better because of the test. "Most of the recommendations on that list are basically saying 'Don't do tests on patients who are doing fine,'" Dr. Lee says.

Part of the demand for "just in case" heart tests is from people pointedly asking their doctors for it. "If someone is feeling fine, we're not going to make them feel better or live longer," Dr. Lee says. "I always tell patients to take the money they would have spent on a test and join a health club or buy healthier food."

High-tech heart tests

Echocardiography: An echocardiograph bounces sound waves off the heart to gather information about its size, shape, and function. The test can also reveal whether blood is flowing properly through its chambers.

  • Stress echocardiography combines echocardiography with exercise or a medication that makes the heart beat faster. The test shows how well the heart performs under stress, when it is required to work harder.

Nuclear stress test: For this procedure, a mildly radioactive tracer chemical is injected into the blood and is absorbed by heart muscle cells. The heart is forced to beat faster through exercise or a medication, and is then scanned by a special camera to visualize how well blood flows to the heart muscle while it is working harder.

Cardiac CT: Cardiac computed tomography (CT) scanning uses x-rays to produce detailed images of the heart, including its structure and blood supply.

  • CT angiography images the arteries that supply blood to the heart muscle.

  • A coronary artery calcium scoring test uses CT scan information to evaluate the buildup of calcium-rich plaque in the coronary arteries.

Cardiac MRI: Cardiac magnetic resonance imaging (MRI) uses a large magnet and radio waves to produce detailed images of the heart. Unlike cardiac CT, it does not involve exposure to x-rays.

  • MRI angiography images the arteries that supply blood to the heart muscle.