SMA News Digest (Summer 2014): V54, I2 | Page 36

CHOOSING WISELY CANADA

5 things
cardiovascular physicians and patients should question
By the Canadian Cardiovascular Society *

1

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.
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.

2 Don’t perform annual stress cardiac imaging
or advanced non-invasive imaging as part of
routine follow-up in asymptomatic patients.
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.

3

Don’t perform stress cardiac imaging or
advanced non-invasive imaging as a preoperative assessment in patients scheduled
to undergo low-risk non-cardiac surgery.

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.

4

Don’t perform echocardiography as routine follow-up for mild, asymptomatic na-

34

SMA NEWS DIGEST | SUMMER 2014

tive valve disease in adult patients with no
change in signs or symptoms.
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.

5

Don’t order annual electrocardiograms
(ECGs) for low-risk patients without symptoms.

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.

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.