Cardiology

Eight Tests and Treatments to Question

by
Canadian Cardiovascular Society
Last updated: May 2024

Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
1

Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening”. Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events.

Sources:

American College of Cardiology Foundation Appropriate Use Criteria Task Force, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PMID: 21349406.

Dowsley T, et al. The role of noninvasive imaging in coronary artery disease detection, prognosis, and clinical decision making. Can J Cardiol. 2013 Mar;29(3):285-96. PMID: 23357601.

Hendel RC, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging. Circulation. 2009 Jun 9;119(22):e561-87. PMID: 19451357.

Natarajan MK, et al. Canadian Cardiovascular Society position statement on radiation exposure from cardiac imaging and interventional procedures. Can J Cardiol. 2013 Nov;29(11):1361-8. PMID: 24035289.

Taylor AJ, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. J Am Coll Cardiol. 2010 Nov 23;56(22):1864-94. PMID: 21087721.

Related Resources:

Patient Pamphlet: ECG (Electrocardiogram): When you need it and when you don’t

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Patient Pamphlet: Chest X-rays Before Surgery: When you need them and when you don’t
Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
2

Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation.

Sources:

American College of Cardiology Foundation Appropriate Use Criteria Task Force, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PMID: 21349406.

Hendel RC, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging. Circulation. 2009 Jun 9;119(22):e561-87. PMID: 19451357.

Natarajan MK, et al. Canadian Cardiovascular Society position statement on radiation exposure from cardiac imaging and interventional procedures. Can J Cardiol. 2013 Nov;29(11):1361-8. PMID: 24035289.

Related Resources:

Patient Pamphlet: ECG (Electrocardiogram): When you need it and when you don’t

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Patient Pamphlet: Chest X-rays Before Surgery: When you need them and when you don’t
Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
3

Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery (e.g., cataract removal). These types of tests do not change the patient’s clinical management or outcomes.

Sources:

American College of Cardiology Foundation Appropriate Use Criteria Task Force, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PMID: 21349406.

Fleisher LA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241. PMID: 17950140.

Hendel RC, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging. Circulation. 2009 Jun 9;119(22):e561-87. PMID: 19451357.

Natarajan MK, et al. Canadian Cardiovascular Society position statement on radiation exposure from cardiac imaging and interventional procedures. Can J Cardiol. 2013 Nov;29(11):1361-8. PMID: 24035289.

Related Resources:

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t

Patient Pamphlet: Chest X-rays Before Surgery: When you need them and when you don’t

Toolkit: Drop the Pre-Op – A toolkit for reducing unnecessary visits and investigations in pre-operative clinics
Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
4

Patients with native valve disease usually have years without symptoms before the onset of deterioration. An echocardiogram is not recommended yearly unless there is a change in clinical status.

Sources:

American College of Cardiology Foundation Appropriate Use Criteria Task Force, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. PMID: 21349406.

Cardiac Care Network. Standards for provision of echocardiography in Ontario [Internet]. 2012 [cited 2014 Feb 19].

Related Resources:

Patient Pamphlet: Echocardiogram Before Surgery: When you need it and when you don’t
Don’t order annual electrocardiograms (ECGs) for low-risk patients without symptoms.
5

Don’t obtain screening electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%), screening for coronary heart disease with electrocardiography does not improve patient outcomes.

Sources:

U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography [Internet]. 2012 Jul [cited 2014 Feb 19].

Related Resources:

Patient Pamphlet: ECG (Electrocardiogram): When you need it and when you don’t
Don’t offer therapies on the basis of survival benefit without establishing your patient’s prognosis, preferences, and goals of care.
6

It is often the path of least resistance to follow medical care algorithms and escalate care as patient’s require it. However, it has been consistently shown that patients value goals of care discussions to better understand prognosis and possible next therapeutic steps. These discussions enhance patient care and help avoid unnecessary interventions.

Sources:

Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010 Mar 23;340:c1345. PMID: 20332506.

Shaw M, Shaw J, Simon J. Listening to Patients’ Own Goals: A Key to Goals of Care Decisions in Cardiac Care. Can J Cardiol. 2020 Jul;36(7):1135-1138. PMID: 32348846.
Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T.
7

Unlike CK-MB and myoglobin, the release of troponin I or T is specific to cardiac injury.

Troponin is released before CK-MB and appears in the blood as early as, if not earlier than, myoglobin after AMI. Approximately 30% of patients experiencing chest discomfort at rest with a normal CK-MB will be diagnosed with AMI when evaluated using troponins. Single-point troponin measurements equate to infarct size for the determination of the AMI severity. Accordingly, there is much support for relying solely on troponin and discontinuing the use of CK-MB and other markers.

Sources:

Amsterdam et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-228. PMID: 25260718.

Eggers KM, Oldgren J, Nordenskjold A, et al. Diagnostic value of serial measurement of cardiac markers in patients with chest pain: limited value of adding myoglobin to troponin I for exclusion of myocardial infarction. Am Heart J 2004;148:574–81. PMID: 15459585.

Kavsak PA, MacRae AR, Newman AM, et al. Effects of contemporary troponin assay sensitivity on the utility of the early markers myoglobin and CKMB isoforms in evaluating patients with possible acute myocardial infarction. Clin Chim Acta 2007;380:213–6. PMID: 17306781.

Kontos MC, de Lemos JA, Ou FS, et al. Troponin positive, MB-negative patients with non-ST-elevation myocardial infarction: an undertreated but high-risk patient group: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (NCDR ACTION-GWTG) Registry. Am Heart J 2010;160:819–25. PMID: 21095267.

Volz KA, McGillicuddy DC, Horowitz GL, et al. Creatine kinase-MB does not add additional benefit to a negative troponin in the evaluation of chest pain. Am J Emerg Med 2012;30:188–90. PMID: 21129891.

Newby LK, Roe MT, Chen AY, et al. Frequency and clinical implications of discordant creatine kinase-MB and troponin measurements in acute coronary syndromes. J Am Coll Cardiol 2006;47:312–8. PMID: 16412853.
Don't exclusively offer centre-based cardiac rehabilitation when home-based cardiac rehabilitation programs can be offered for adults with myocardial infarction, angina, heart failure or those who have undergone revascularisation.
8

Cardiac rehabilitation is crucial in the treatment of patients living with cardiovascular disease. These structured programs improve the physical, psychological, and social well-being of individuals with specific conditions or following a cardiovascular event or procedure. They are typically delivered on-site and include supervised exercise training, education on heart-healthy behaviors, nutritional guidance, stress management techniques, and psychosocial support. The development and evaluation of in-home programs with or without the use of digital support have been compared with centre-based rehabilitation in a recent systematic review that assessed a total of 24 trials and included a total of 3046 participants. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in terms of total mortality, exercise capacity or in health-related quality of life. We can therefore offer an alternate effective model of programming in appropriate patients in their home environments and limit travel.

Centre-based cardiac programs vary in terms of travel distance for patients, frequency, and duration. It is estimated that home-based program could reduce the need for trips to on-site facilities by 50-75%. Driving contributes significantly to Canada’s carbon footprint, with transportation being one of the largest sources of greenhouse gas emissions in the country. Addressing transportation-related emissions, including those associated with driving to healthcare facilities, is crucial for mitigating climate change.

Sources:

McDonagh_STJ, Dalal_H, Moore_S, Clark_CE, Dean_SG, Jolly_K, Cowie_A, Afzal_J, Taylor_RS. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2023, Issue 10. Art. No.: CD007130. DOI: 10.1002/14651858.CD007130.pub5. PMID: 37888805.
How the list was created

The Canadian Cardiovascular Society (CCS) established its Choosing Wisely Canada top 5 recommendations by working closely with the American College of Cardiology (ACC). The ACC provided the CCS with the literature review, complete to 2009, that had informed their top 5 recommendations. This provided a strong foundation for the CCS to begin its investigation into relevant top 5 recommendations for cardiac care in the Canadian context. The CCS then conducted an extensive literature review to include all relevant publications since January 1, 2009. Moreover the CCS also included all relevant existing Canadian Guidelines, any Canadian appropriate use criteria and Canadian national or provincial policies that pertained to the five statements. The CCS then performed an extensive dissemination and consultation with its membership via email, Facebook, Twitter, the annual national meeting and webinars to ensure awareness and approval of the top 5 recommendations. The first four items were adapted with permission from the Five Things Physicians and Patients Should Question, ©2012 American College of Cardiology. Item 5 was adapted with permission from the Five Things Physicians and Patients Should Question, ©2012 American College of Family Medicine.