Cardiology

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.