Cardiology
Canadian Cardiovascular Society
Last updated: September 2025
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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.
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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.
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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.
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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]. 2021 [cited 2021].
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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:
Moyer VA, et al. Screening for coronary heart disease with electrocardiography. Ann Intern Med. 2012 Oct 2;157(7):512-8. PMID: 22847227.
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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, et al. 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, et al. 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.
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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, 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, 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, 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.
Newby LK, 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.
Volz KA, 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.
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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, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2023;10:CD007130. PMID: 37888805.
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Early conversations about disease understanding, wishes, and goals with patients who have serious or progressive chronic illnesses can avoid potentially harmful tests or treatments. Ensuring patients discuss and document wishes and goals, as well as identify a substitute decision-maker can support evidence-informed and patient-centered care.
Sources:
Bernacki RE, et al. for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994–2003. PMID: 25330167.
Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010; 340:1345. PMID: 20332506.
Weathers E, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas. 2016;91:101–109. PMID: 27451328.
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Gloves don’t need to be used for most routine healthcare interactions with certain exceptions. Unnecessary use of gloves is common, leads to increased costs, generates waste and may inadvertently increase rates of cross-contamination. A study in the Netherlands found that >100 disposable gloves were used in the ICU per patient per day contributing to the highest carbon footprint compared to other commonly used products.
Sources:
Canada’s Drug Agency. CADTH Health Technology Review: Non-sterile glove use. [Internet]. 2023 [cited 2025].
Hunfeld N, et al. Circular material flow in the intensive care unit—environmental effects and identification of hotspots. Intensive Care Medicine. 2023;49(1):65-74. PMID: 36480046.
Loveday HP, et al. Clinical glove use: healthcare workers’ actions and perceptions. J Hosp Infect. 2014 Feb;86(2):110-6. Epub 2013 Nov 28. PMID: 24412643.
World Health Organization. Glove use information leaflet. [Internet]. 2009 [cited 2025 June].
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Running a CBC and electrolyte panel on a patient produces 0.3597kg CO2e (1.75km by car). Daily bloodwork seldom changes outcomes, exposes patients to harms (venipuncture associated pain, wake from sleep), and is associated with negative outcomes including anemia and need for transfusions. Routine and repetitive bloodwork can be safely discontinued through targeted interventions without increasing outcomes like re-admission, ICU admission, or mortality.
Sources:
Silverstein WK, et al. Reducing routine inpatient blood testing. BMJ. 2022;379:e070698. PMID: 36288811.
Spoyalo K, et al. Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients. BMJ open quality. 2023;12(3). PMID: 37402596.
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Virtual care is a safe, effective, and environmentally friendlier alternative to traditional office visits in many chronic health conditions such as hypertension, diabetes, and frailty management/eldercare. In 2021, virtual care in Canada contributed to an estimated reduction of 330,000 metric tons of CO2. A study looking at the environmental impact of telemedicine in Ontario estimated that 185 159kg CO2e or 757 234km were avoided by conducting 840 appointments virtually over a 6-month period. Many provinces support equal remuneration between virtual and in-person care.
Sources:
Canadian Institute for Health Information. Physician billing codes in response to COVID-19. [Internet]. 2024 [cited 2025 June].
Masino C, et al. The impact of telemedicine on greenhouse gas emissions at an academic health science center in Canada. Telemed J E Health. 2010 Nov;16(9):973-6. Epub 2010 Oct 19. PMID: 20958198.
Pickard Strange M, et al. The Role of Virtual Consulting in Developing Environmentally Sustainable Health Care: Systematic Literature Review. J Med Internet Res. 2023;25:e44823. PMID: 37133914.
Simms N. The environmental benefits of virtual care utilization in Canada: An analysis of travel distance avoided and associated carbon reductions as reported in the Canada Health Infoway Canadian Digital Health Survey 2021: What Canadians Think. White Papers. [Internet]. 2022 [cited 2025 June].
Welk B, et al. Association of Virtual Care Expansion With Environmental Sustainability and Reduced Patient Costs During the COVID-19 Pandemic in Ontario, Canada. JAMA Netw Open. 2022 Oct 3;5(10):e2237545. PMID: 36264577.
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Ensuring proper medication disposal is crucial to minimize health risks, preventing misuse and adverse effects. Less than 1% of patients return unused medication, increasing the likelihood of accidental ingestion by children and pets. Flushing medications down the toilet, a prevalent disposal method, poses risks of antibiotic resistance and water contamination. The improper disposal introduces pharmaceutical residue into water systems, threatening aquatic life. Education on safe disposal and encouraging return to designated collection sites can reduce these risks. Regulatory measures, such as those implemented in British Columbia, aim to address pharmaceutical waste through recycling regulations, highlighting the importance of comprehensive strategies to minimize environmental harm.
Sources:
Afanasjeva J, et al. Pharmacists as environmental stewards: Strategies for minimizing and managing drug waste. Sustainable Chemistry and Pharmacy. 2019;13:100164.
Haas C. Environmental Paper Organization. Ending 90 Billion Sheets: The Environmental Impact of Pharmaceutical Paper Waste. [Internet]. 2023 Sep [cited 2025 June].
Insani WN, et al. Improper disposal practice of unused and expired pharmaceutical products in Indonesian households. Heliyon. 2020 Jul 29;6(7):e04551. PMID: 32760838.
Owens L, et al. MEDICATION DISPOSAL SURVEY Final Report. University of Illinois Survey Research Laboratory. [Internet]. 2009 [cited 2025 June].
Qadar SMZ, et al. A Call to Action: An Evidence Review on Pharmaceutical Disposal in the Context of Antimicrobial Resistance in Canada. National Collaborating Centre for Infectious Diseases. [Internet]. Jan 2021 [cited 2025 June].
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There is emerging evidence that conditions traditionally treated with prolonged courses of IV antibiotics, such as osteomyelitis or infective endocarditis, can safely be treated with PO antibiotics after a lead in period of IV therapy. Studies from the UK estimated that oral antibiotics have a carbon footprint up to 90% lower than the IV equivalent, depending on the antibiotic – a one-week course of oral ciprofloxacin is associated with 1.4kg CO2e (6.8km by car) of emissions versus 100.1kg CO2e (485.9km by car) for intravenous ciprofloxacin. The same group ran an early oral antimicrobial step-down project which saved 300,000 British pounds (or ~$450,000 CAD) annually. Among patients on IV antibiotics, early transition to oral antibiotics has the additional co-benefits of reducing hospital length of stay, length of treatment, nursing care needs, in addition to lowering carbon footprint.
*All kgCO2e to km conversions in these recommendations are based on a carbon footprint conversion factor of 206gCO2e/km for the average Canadian vehicle in 2017. From: International Energy Agency. Fuel Economy in Major Car Markets: Technology and Policy Drivers 2005-2017. March 2019.
Sources:
Harvey EJ, et al. Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid. J Clin Med. 2023;12(6). PMID: 36983089.
Health Quality Ontario. Criteria for Switching From Intravenous to Oral Antibiotics in Patients Hospitalized With Community Acquired Pneumonia: A Rapid Review. [Internet]. 2013 [cited 2025 June].
Iversen K, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. New England Journal of Medicine. 2018;380(5):415-24. PMID: 30152252.
Li H-K, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. New England Journal of Medicine. 2019;380(5):425-36. PMID: 30699315.
Walpole S, et al. Medicines are responsible for 22% of the NHS’s Carbon Footprint: How do the footprints of intravenous and oral antibiotics compare? Federation of Infection Societies Conference; Manchester 2021. 186:38.
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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.
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Choosing Wisely Canada’s climate-conscious recommendations are developed by clinician societies to improve planetary health without compromising patient care. These recommendations highlight everyday practices we can reduce or eliminate to minimize environmental harm. Visit our climate page to explore all the recommendations and learn more.
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.
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.
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.
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]. 2021 [cited 2021].
Moyer VA, et al. Screening for coronary heart disease with electrocardiography. Ann Intern Med. 2012 Oct 2;157(7):512-8. PMID: 22847227.
Detering KM, et al. 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, et al. 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.
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, 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, 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, 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.
Newby LK, 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.
Volz KA, 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.
McDonagh STJ, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews 2023;10:CD007130. PMID: 37888805.
Bernacki RE, et al. for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994–2003. PMID: 25330167.
Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010; 340:1345. PMID: 20332506.
Weathers E, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas. 2016;91:101–109. PMID: 27451328.
Canada’s Drug Agency. CADTH Health Technology Review: Non-sterile glove use. [Internet]. 2023 [cited 2025].
Hunfeld N, et al. Circular material flow in the intensive care unit—environmental effects and identification of hotspots. Intensive Care Medicine. 2023;49(1):65-74. PMID: 36480046.
Loveday HP, et al. Clinical glove use: healthcare workers’ actions and perceptions. J Hosp Infect. 2014 Feb;86(2):110-6. Epub 2013 Nov 28. PMID: 24412643.
World Health Organization. Glove use information leaflet. [Internet]. 2009 [cited 2025 June].
Silverstein WK, et al. Reducing routine inpatient blood testing. BMJ. 2022;379:e070698. PMID: 36288811.
Spoyalo K, et al. Patient, hospital and environmental costs of unnecessary bloodwork: capturing the triple bottom line of inappropriate care in general surgery patients. BMJ open quality. 2023;12(3). PMID: 37402596.
Canadian Institute for Health Information. Physician billing codes in response to COVID-19. [Internet]. 2024 [cited 2025 June].
Masino C, et al. The impact of telemedicine on greenhouse gas emissions at an academic health science center in Canada. Telemed J E Health. 2010 Nov;16(9):973-6. Epub 2010 Oct 19. PMID: 20958198.
Pickard Strange M, et al. The Role of Virtual Consulting in Developing Environmentally Sustainable Health Care: Systematic Literature Review. J Med Internet Res. 2023;25:e44823. PMID: 37133914.
Simms N. The environmental benefits of virtual care utilization in Canada: An analysis of travel distance avoided and associated carbon reductions as reported in the Canada Health Infoway Canadian Digital Health Survey 2021: What Canadians Think. White Papers. [Internet]. 2022 [cited 2025 June].
Welk B, et al. Association of Virtual Care Expansion With Environmental Sustainability and Reduced Patient Costs During the COVID-19 Pandemic in Ontario, Canada. JAMA Netw Open. 2022 Oct 3;5(10):e2237545. PMID: 36264577.
Afanasjeva J, et al. Pharmacists as environmental stewards: Strategies for minimizing and managing drug waste. Sustainable Chemistry and Pharmacy. 2019;13:100164.
Haas C. Environmental Paper Organization. Ending 90 Billion Sheets: The Environmental Impact of Pharmaceutical Paper Waste. [Internet]. 2023 Sep [cited 2025 June].
Insani WN, et al. Improper disposal practice of unused and expired pharmaceutical products in Indonesian households. Heliyon. 2020 Jul 29;6(7):e04551. PMID: 32760838.
Owens L, et al. MEDICATION DISPOSAL SURVEY Final Report. University of Illinois Survey Research Laboratory. [Internet]. 2009 [cited 2025 June].
Qadar SMZ, et al. A Call to Action: An Evidence Review on Pharmaceutical Disposal in the Context of Antimicrobial Resistance in Canada. National Collaborating Centre for Infectious Diseases. [Internet]. Jan 2021 [cited 2025 June].
Harvey EJ, et al. Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid. J Clin Med. 2023;12(6). PMID: 36983089.
Health Quality Ontario. Criteria for Switching From Intravenous to Oral Antibiotics in Patients Hospitalized With Community Acquired Pneumonia: A Rapid Review. [Internet]. 2013 [cited 2025 June].
Iversen K, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. New England Journal of Medicine. 2018;380(5):415-24. PMID: 30152252.
Li H-K, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. New England Journal of Medicine. 2019;380(5):425-36. PMID: 30699315.
Walpole S, et al. Medicines are responsible for 22% of the NHS’s Carbon Footprint: How do the footprints of intravenous and oral antibiotics compare? Federation of Infection Societies Conference; Manchester 2021. 186:38.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Common Tests, Treatments, and Procedures You May Think You Need
Let’s think again.
ECG (Electrocardiogram)
When you need it and when you don’t.
Echocardiogram Before Surgery
When you need one and when you don’t.
Heart Tests Before Surgery
When you need an imaging test and when you don’t.
Using Labs Wisely
A national consortium that’s changing the lab utilization landscape in Canada.
