Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019
To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees’ attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history–electrocardiogram–age–risk factors–troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.
© 2019 Society of Hospital Medicine
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. Fernando S, et al. Acad Emerg Med. 2019;26(2):140-151.13
Background. Chest pain accounts for over eight million emergency department (ED) visits yearly in the United States. Of those presenting with chest pain, 10%-20% will experience acute coronary syndrome (ACS) requiring further medical treatment. Given the fear of missing ACS, many low-risk patients are hospitalized. The American Heart Association has advocated using validated predictive scoring models to identify patients with chest pain who are at low risk for short-term major cardiovascular adverse event (MACE) for potential discharge without further testing. The authors evaluated the prognostic accuracy of higher risk scores to predict MACE in adult ED patients presenting with chest pain.
Findings. This study was a systematic review and meta-analysis of 30 prospective and retrospective studies evaluating the history–electrocardiogram–age–risk factors–troponin (HEART) score through May 1, 2018. Meta-analysis compared the sensitivity, specificity, positive likelihood ratios, negative likelihood ratios, and diagnostic odds ratios of the HEART score and the Thrombolysis in Myocardial Infarction (TIMI) score when reported. An intermediate HEART score of 4-6 had a sensitivity of 95.9% and a specificity of 44.6%. A high HEART score of greater than or equal to 7 had a sensitivity of 39.5% and a specificity of 95.0%. Similarly, a high TIMI score of great than or equal to 6 had a sensitivity of only 2.8% and a specificity of 99.6%. The authors concluded that a HEART score of greater than or equal to 4 best identifies patients at risk of MACE who need greater consideration for additional testing.
Caveats. This meta-analysis failed to assess the potential adverse effects of false positive downstream testing. Additionally, no study compared the HEART score with the experienced clinician gestalt, which has often been equivalent to decision rules.
Implication. A HEART score greater than or equal to 4 risk stratifies ED patients with chest pain requiring further consideration for evaluation versus those that can be discharged with low risk for short-term MACE.
