What screening test(s) for cardiovascular disease should be recommended for this patient?A 52-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He has no significant medical history and takes no medications regularly. His father died at the age of 74 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has two younger siblings with no known chronic medical conditions. He does not smoke cigarettes, drink alcohol, use any recreational drugs, and does not exercise. On examination, his blood pressure is 127/82 mm Hg, pulse is 80 beats/min, respiratory rate is 18 breaths/min, height is 67 in, and weight is 190 lb. On careful physical examination, no abnormalities are noted.
What screening test(s) for cardiovascular disease should be recommended for this patient?
What screening test(s) for cancer should be recommended?
What immunization(s) should be recommended?
Summary: A 52-year-old man with no active medical problems is being evaluated during an “annual physical.” He has no complaints on history and has a normal physical examination.
• Recommended screening tests for cardiovascular conditions: Blood pressure measurement (screening for hypertension) and lipid measurement (screening for dyslipidemia)
• Recommended screening tests for cancer: Fecal occult blood testing, flexible sigmoidoscopy (with or without occult blood testing), colonoscopy or double-contrast barium enema to screen for colorectal cancer; there is insufficient evidence to recommend for or against universal prostate cancer screening by prostate-specific antigen (PSA) testing
• Recommended immunizations: Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) if he has not had one before and if it has been 10 years or more since he has had a tetanus-diphtheria (Td) vaccine or if he requires booster protection against pertussis; influenza vaccine annually, in the fall or winter months
Objectives
1. Know the components of an adult health-maintenance visit.
2. Learn the screening tests and immunizations that are routinely recommended for adult men.
The patient described is a healthy 52-year-old man. Health maintenance should be employed to prevent future disease. In general, the approach is immunizations, cancer screening, and screening for common diseases. Generally, colon cancer screening should be initiated at age 50 and beyond. The influenza vaccine should be recommended annually, and the tetanus vaccine every 10 years. The acellular pertussis vaccine is also recommended as many adults have had waning immunity to pertussis and occasional outbreaks of whooping cough have been noted. Since cardiovascular disease is the most common cause of mortality in his age group, screening for cardiovascular disease or risk factors is appropriate.
SCREENING TEST: Assessment device or test that should be cost effective with high sensitivity and can be used on a large population to identify persons with disease
HEALTH MAINTENANCE: Preventative care for patients prior to development of disease
For years, one of the cornerstones of primary care was the “annual physical,” which often consisted of a complete physical examination, blood tests, including complete blood counts (CBCs) and multichemistry panels, and, frequently, annual chest x-rays and electrocardiograms (ECGs). The concept of the “annual physical,” or “health-maintenance examination” is still important; however, the components of the examination have changed over time.
The purposes of the health-maintenance visit are to identify the individual patient’s health concerns, manage the patient’s current medical conditions, identify the patient’s risks for future health problems, perform rational and cost-effective health screening tests, and promote a healthy lifestyle. Prevention is divided into primary prevention and secondary prevention. Primary prevention is an intervention designed to prevent a disease before it occurs. It usually involves the identification and management of risk factors for a disease. Examples of this would be the use of a statin medication to reduce low-density lipoprotein (LDL) cholesterol in order to lower the risk of coronary artery disease or the removal of colon polyps to prevent the development of colon cancer. Secondary prevention is an intervention intended to reduce the recurrence or exacerbation of a disease. An example of secondary prevention is the use of a statin medication after a person has had a myocardial infarction (MI) so as to reduce the risk of a second heart attack.
Effective screening for diseases or health conditions should meet several established criteria. First, the disease should be of high enough prevalence in the population to make the screening effort worthwhile. There should be a time frame during which the person is asymptomatic, but during which the disease or risk factor can be identified. There needs to be a test available for the disease that has sufficient sensitivity and specificity, is cost-effective, and is acceptable to patients. Finally, there must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality of the disease process.
The United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and preventive medicine that reviews evidence and makes recommendations on the effectiveness of clinical preventive services, specifically in the areas of screening, immunization, preventive medications, and counseling. USPSTF recommendations are “gold standards” for clinical preventive medicine. The recommendations of the USPSTF are available online for free at www.ahrq.gov/clinic/prevenix.htm. USPSTF grades its recommendations in five categories to reflect evidence strength and overall benefit of an intervention. For recommendations released after May 2007, new grade definitions include levels of certainty regarding an intervention’s net benefit and “suggestions for practice.”
Cardiovascular Diseases
Diseases of the cardiovascular system are the leading cause of death in adult men and the management of risk factors for these diseases reduces both morbidity and mortality from these diseases. The USPSTF strongly recommends (Level A1) screening of adults for hypertension by measurement of blood pressure, as screening causes little harm and management of hypertension is effective at reducing the risk of cardiovascular diseases. USPSTF also strongly recommends (Level A) screening men aged 35 years or more and women aged 45 years or more for lipid disorders and recommends (Level B) screening adults older than 20 years who are at increased risk for cardiovascular diseases. The screening can take the form of nonfasting total cholesterol and high-density lipoprotein (HDL)-cholesterol levels or fasting lipid panels that include the low-density lipoprotein (LDL)-cholesterol. Ultrasonography to assess for abdominal aortic aneurysm is recommended (Level B) for men aged 65 to 75 years who have ever smoked. There is no recommendation (Level C) for abdominal aortic aneurysm screening for men who have never smoked and it is recommended against (Level D) for women, regardless of smoking status.
The routine use of electrocardiogram (ECG), exercise stress testing, or computed tomography (CT) scanning for coronary calcium is not recommended (Level D) for screening for coronary artery disease in adults at low risk for coronary events. There is insufficient evidence to recommend for or against these modalities (Level I) in adults at higher risk of coronary events. Screening for peripheral arterial disease in asymptomatic adults is not recommended (Level D) because of the low prevalence of the problem in asymptomatic adults and the lack of evidence for improved outcomes from treatment in the asymptomatic stage.
Cancer
Adults (men and women) older than 50 years are strongly advised (Level A1) to have screening for colorectal cancer. This screening can take the form of fecal occult blood testing (FOBT) using guaiac cards on three consecutive bowel movements collected at home, flexible sigmoidoscopy with or without occult blood testing, or colonoscopy. The optimal intervals for testing are not clear, but FOBT is generally recommended annually, sigmoidoscopy every 3 to 5 years, and colonoscopy every 10 years. An abnormal test result of FOBT or sigmoidoscopy leads to the performance of a colonoscopy.
The USPSTF currently finds insufficient evidence to recommend for or against routine screening (Level I1) for prostate cancer using digital examination or prostate-specific antigen (PSA) in men younger than 75 years. Although testing improves detection of prostate cancer, the evidence for improved outcomes is inconsistent. Level I ratings are also given to screening for lung cancer using CT scanning, chest x-rays, sputum cytology, or combinations of these, and to screening for thyroid cancer, skin cancer (I1), or oral cancer.
Screening for bladder, testicular, or pancreatic cancer in asymptomatic adults is not recommended (Level D). Screening for prostate cancer in asymptomatic men older than 75 years is also not recommended (Level D).
Other Health Conditions
Screening for obesity by measuring body mass index (BMI) and providing intensive counseling and behavioral interventions to promote weight loss are recommended for all adults (Level B1). There is insufficient evidence to recommend screening of asymptomatic adults for type 2 diabetes mellitus (Level I1), although screening is recommended (Level B1) for adults with hypertension or hyperlipidemia. Depression screening is recommended (Level B1) if there are mechanisms in place for ensuring accurate diagnosis, treatment, and follow-up. Screening and counseling to identify and promote cessation of tobacco use is strongly recommended (Level A1). Screening and counseling to identify and prevent the misuse of alcohol is also recommended (Level B).
As is the case for well-child care, the provision of age- and condition-appropriate immunizations is an important component of well-adult care. Recommendations for immunizations change from time to time and the most up-to-date source of vaccine recommendations is the Advisory Committee on Immunization Practices. Its immunization schedules are widely published and are available at the Centers for Disease Control and Prevention Web site (among other places), www.cdc.gov.
The CDC has recently recommended that all adults between 19 and 65 years of age should receive a booster of Tdap in place of a scheduled dose of Td due to waning immunity against pertussis and the presence of an increasing number of cases of pertussis nationwide. Adults who have not had a Td booster in 10 years or more and who have never had a dose of Tdap as an adult should receive a booster vaccination with Tdap. Persons who may need an increase in protection against pertussis, including health-care workers, childcare providers, or those who anticipate having close contact with infants younger than 1 year, should also receive a Tdap booster. An interval of 2 years from the last Td is recommended, although a shorter interval may be used if necessary.
In a 2010 update, the CDC is recommending influenza vaccination for everyone 6 months of age and older. This replaces a recommendation of vaccination based upon risk factors.
Pneumococcal polysaccharide vaccination is recommended as a single dose for all adults aged 65 years or older. It is also recommended for adults younger than 65 years who are alcoholics or smokers; have chronic cardiovascular, pulmonary (including asthma), renal, or hepatic diseases; diabetes; an immunodeficiency; or who are functionally asplenic. One-time revaccination after 5 years is recommended for those with immunocompromising conditions and asplenia. One-time revaccination is also recommended for those older than 65 years if they were vaccinated longer than 5 years previously and were younger than 65 years at the time of initial vaccination.
Other vaccinations may be recommended for specific populations, although not for all adults. Hepatitis B vaccination should be recommended for those at high risk of exposure, including health-care workers, those exposed to blood or blood products, dialysis patients, intravenous drug users, persons with multiple sexual partners or recent sexually transmitted diseases, and men who engage in sexual relations with other men. Hepatitis A vaccine is recommended for persons with chronic liver disease, who use clotting factors, who have occupational exposure to the hepatitis A virus, who use IV drugs, men who have sex with men, or who travel to countries where hepatitis A is endemic. Varicella vaccination is recommended for those with no reliable history of immunization or disease, who are seronegative on testing for varicella immunity, and who are at risk for exposure to varicella virus. Meningococcal vaccine is recommended for persons in high-risk groups, college dormitory residents and military recruits, with certain complement deficiencies, functional or anatomic asplenia, or who travel to countries where the disease is endemic.
Along with the discussion of screening and promotion of tobacco cessation and prevention of alcohol misuse, other aspects of healthy living should be promoted by physicians. Exercise has been consistently shown to reduce the risk of cardiovascular disease, diabetes, obesity, and overall mortality. Even exercise of moderate amounts, such as walking for 30 minutes on most days of the week, has a positive effect on health. The benefits increase with increasing the amount of exercise performed. Studies performed on counseling physically inactive persons to exercise have shown inconsistent results. However, the benefits of exercise are clear and should be promoted. Counseling to promote a healthy diet in persons with hyperlipidemia, other risk factors for cardiovascular disease, or other conditions related to diet is beneficial. Intensive counseling by physicians or, when appropriate, referral to dietary counselors or nutritionists, can improve health outcomes. In selected patients, recommendations regarding safer sexual practices, including the use of condoms, may be appropriate to reduce the risk or recurrence of sexually transmitted diseases. Finally, all patients should be encouraged to use seat belts and avoid driving while under the influence of alcohol or drugs, as motor vehicle accidents remain a leading cause of morbidity and mortality in adults.
1.1 A 52-year-old man comes into the outpatient clinic for an annual “checkup.” He is in good health, and has a relatively unremarkable family history. For which of the following disorders should a screening test be performed?
A. Prostate cancer
B. Lung cancer
C. Abdominal aortic aneurysm
D. Colon cancer
1.2 A 62-year-old man with recently diagnosed emphysema presents to your office in November for a routine examination. He has not had any immunizations in more than 10 years. Which of the following immunizations would be most appropriate for this individual?
A. Tetanus-diphtheria (Td) only
B. Tdap, pneumococcal, and influenza
C. Pneumococcal and influenza
D. Tdap, pneumococcal, influenza, and meningococcal
1.3 A 49-year-old sedentary man has made an appointment because his best friend died of an MI at age 50. He asks about an exercise and weight loss program. In counseling him, which of the following statements regarding exercise is most accurate?
A. To be beneficial, exercise must be performed everyday.
B. Walking for exercise has not been shown to improve meaningful clinical outcomes.
C. Counseling patients to exercise has not been shown consistently to increase the number of patients who exercise.
D. Intense exercise offers no health benefit over mild to moderate amounts of exercise.
1.1 D. Colon cancer screening is given a Level A1 recommendation by the USP-STF and is routinely offered or provided to all adults older than 50 years. There is insufficient evidence to recommend for or against routine lung or prostate cancer screening. Abdominal aortic aneurysm screening is recommended in men aged 65 to 75 years who have smoked.
1.2 B. In an adult with a chronic lung disease, one-time vaccination with pneumococcal vaccine and annual vaccination with influenza vaccine are recommended. A Tdap booster should be recommended to all adults who have not had a Td booster within 10 years and have never had a Tdap vaccine as an adult.
1.3 C. The benefits of exercise are clear. Exercise decreases cardiovascular risk factors, increases insulin sensitivity, decreases the incidence of the metabolic syndrome, and decreases cardiovascular mortality regardless of obesity. The benefits of counseling patients regarding exercise are not so clear and counseling does not seem to increase the number of patients who exercise.
There is no such thing as “routine blood tests” or a “routine chest x-ray.” All tests that are ordered should have evidence to support their benefit.
High-quality, evidence-based recommendations for preventive health services are available at www.uspreventiveservicestaskforce.org.
Blaha, MJ, Bansal S, Rouf R, Golden SH, Blumenthal RS, Defilippis AP. A Practical “ABCDE” Approach to the Metabolic Syndrome. Mayo Clin Proc. August 2008;83(8): 932-943.
Centers for Disease Control and Prevention Web site: http://www.cdc.gov.
United States Preventive Services Task Force Web site: http://www.uspreventiveservicestaskforce.org.