If you are worried about your heart attack risk, which screening tests should you get and when?

For healthy patients over age 40, I like to get a electrocardiogram (ECG or EKG) every 2-5 years, and more often if they are older or have existing or new risk factors for coronary artery disease. The main reason for this is not to look for signs of heart disease, but to have a baseline for comparison to help interpret any potential abnormal ECG findings in the future.

Echocardiograms are not appropriate as screening tests but are useful for evaluating suspected abnormalities of the heart valves or reduced overall heart function.

A stress test is not necessary for active people without symptoms of angina. However, this test may be appropriate for sedentary people over age 50 with multiple cardiac risk factors, especially before they begin an exercise regimen.

For patients with new symptoms that suggest angina, a stress test is usually the first diagnostic step. If the stress test is positive (abnormal), then a procedure called catheterization is used to get a better look inside the arteries and determine the best treatment approach.

Sometimes the results of a stress test are not clearly normal or abnormal. In those cases coronary CT calcium scoring can be used to measure the amount of calcium in the arteries. Since most plaque contains calcium, this test indirectly measures plaque buildup and can help determine whether or not a catheterization is necessary.

Coronary CT testing is often marketed as a screening test for heart disease risk. However, finding coronary calcification in the absence of any symptoms doesn't tell your doctor enough information. You would still need a functional test (a stress test) to determine if your high calcium score actually represents a problem that needs treatment.

Another CT test, called a coronary CT angiogram, can generate remarkable images that provide similar information as a standard catheterization. The advantage of a CT angiogram is that it doesn't require inserting a catheter, but it still has risks associated with radiation exposure and costs a lot more than the CT calcium score. CT angiography is still being evaluated, and is probably most valuable in patients who are thought to possibly have coronary artery disease based on other non-invasive testing, but in whom a standard catheterization is especially risky.

I generally don't recommend routine screening tests looking for coronary artery disease. Instead, my advice is to concentrate your efforts on controlling all of your modifiable risk factors, in order to prevent future plaque from forming.