Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
Major risk factors for vascular disease include older age, male sex, hypertension, smoking, dyslipidaemia and diabetes. Calculators using cardiovascular risk factors are widely available to determine a patient's individual risk for a vascular event. The additional information obtained by screening asymptomatic adults at low risk for a vascular event, via a resting ECG or stress test, is very unlikely to alter risk stratification or reduce overall events related to coronary artery disease. The potential harms of these tests have been found to equal or exceed the potential benefits in this population.
In the absence of clinical trial data demonstrating an overall benefit, coronary artery calcium score is also not recommended in this population (National Vascular Disease Prevention Alliance (NVDPA) guidelines.
Similarly, screening with carotid duplex ultrasound in low-risk patients results in many more false-positive than true-positive results. This in turn leads to a significant number of unnecessary angiographies or surgical procedures, with the attendant risks of stroke, myocardial infarction and death.
Recommendation released April 2015
- Chou R, Arora B, Dana T, et al. Screening asymptomatic adults for coronary heart disease with resting or exercise electrocardiography: systematic review to update the 2004 U.S. Preventive Services Task Force recommendation. Evidence Synthesis No. 88. AHRQ Publication No. 11-05158-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
- Desai CS, Blumenthal RS, Greenland P. Screening low-risk individuals for coronary artery disease. Curr Atherosclerosis Rep 2014: Apr;16(4):402.
- Jonas DE, Feltner C, Amick HR, et al. Screening for asymptomatic carotid artery stenosis: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2014 Sep 2;161(5):336-46 2014.
- NVDPA Absolute cardiovascular risk guidelines.
Recommendations 1 - 5 (April 2015)
All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.
Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.
Recommendations 6-10 (March 2016)
The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.
- 1 Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- 2 Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- 3 Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 4 Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 6 Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- 7 Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- 8 Don’t routinely do a pelvic examination with a Pap smear.
- 9 Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- 10 Don’t test thyroid function as population screening for asymptomatic patients.