WEEKLY EBM UPDATE: 12/14/2018

Welcome to the Weekly EBM Update!!

I hope you all are having a nice Friday and getting excited for the holiday party tonight (whoo!). If you can, please remember to bring a donation for the neighborhood house charity.

This weeks articles include a nice meta-analysis evaluating the utility of the HEART score for predicting cardiac events in patients presenting to the ED with chest pain (thanks to the great Brook Pittenger for sending this my way!), and a very nice/interesting article on the overuse of diagnostics and therapeutics in medicine in 2017.

The articles, and the original TIMI article, are attached below!


Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac

Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis (AEM 10/2018)

Multiple risk stratification tools have been created to better predict major adverse cardiac events (MACE) of patients presenting to the ED with chest pain. One of the most common predictive tools used in the inpatient setting is the composite, 7-variable TIMI Risk score created from data generated in the Thrombolysis In Myocardial Infarction (TIMI) 11B trial (a phase 3 trial comparing LMWH to unfractionated heparin in UA/NSTEMI patients). This score risk stratifies patients into low (0-2) or high risk (>2) groups that guides triage and management, though this dichotomous arrangement is somewhat arbitrary, as the risk increases continuously based on number of risk factors. Another predictive risk score, the Global Registry of Acute Coronary Events (GRACE) score is predictive of in-hospital and 6-month mortality from cardiovascular events outperformed the TIMI risk score in stratifying US/NSTEMI patients. The authors of the above study conducted a meta-analysis including 30 studies (n=44,202) to determine the sensitivity and specificity of the 5-variable HEART score compared to the TIMI score in stratifying patients presenting to the ED with acute chest pain. The authors found that a score above the low risk threshold (4) had higher sensitivity (95.9%) compared to the TIMI score (87.8%) for identifying MACE, particularly for short term mortality (95% sensitive) and MI (96.5% sensitive). Higher HEART scores had slightly lower specificity for MACE compared to TIMI (7), (95% vs. 99.6% respectively). The importance of the HEART score is in the role of ED risk stratification, as the TIMI and GRACE scores are validated prognostication tools utilized amongst inpatient cohorts presenting with ACS rather than patients presenting with chest pain to the ED. 

Take Home: For patients presenting to the ED with chest pain, the HEART score outperforms both the TIMI and GRACE for identifying patients at high risk of MACE and helps identify patients suitable for discharge (HEART score < 4) or admission (4). The TIMI and GRACE scores remain validated inpatient prognostic tools to help guide therapeutic decision making amongst patients with unstable angina/NSTEMI.

Study available here

Original TIMI study here


2018 Update on Medical Overuse (JAMA 12/2018)

One task of all healthcare providers is to provide high quality, cost conscious care to patients. This mission led to the creation of the American Board of Internal Medicine (ABIM) Choosing Wiselycampaign in 2012- highlighting the “top five” tests or procedures that were overused amongst medicine specialties in order to reduce unnecessary, harmful, and costly testing or treatments. The authors of the above article reviewed 910 articles (111 included), identifying 10 of the most influential studies in 2017 addressing medical overuse.  The 10 included findings, with the supporting evidence were:

1.     Unnecessary EKG’s appear to be common.

2.     Lipid panels commonly ordered in statin-treated patients appear to seldomly affect care.

3.     Over diagnosed cancer can be difficult on patients (in particular Thyroid cancer, discussed here)

4.     Calcium and Vitamin D supplementation do not appear to reduce fracture risk among community-dwelling adults.

5.     Pregabalin may be ineffective for sciatica, with frequent adverse effects

6.     No apparent benefit of antipsychotics for delirium in palliative care

7.     Robotic-assisted surgery for radical nephrectomy does not appear to improve outcomes

8.     High-sensitivity troponin test results rarely reflect myocardial infarction (type 1)

9.     Many patients with a diagnosis of asthma do not have asthma

10.   Restructuring the electronic health record to prevent over testing

Take Home: Over testing and treatment, whether intentional or unintentional, remains common amongst healthcare service providers today. While a paucity of evidence exists for a substantial portion of our diagnostics and therapeutics, providers should strive to review and use the current evidence when available to provide patients with high-quality, low(est) cost care when able. 

Link to Study