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Annals of Internal Medicine Tip Sheet
April 25, 2017


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. Using HEART score to risk stratify patients with chest pain is safe but underutilized in the ED

Abstract: http://annals.org/aim/article/doi/10.7326/M16-1600

It is safe for physicians to use the HEART (History, ECG, Age, Risk factors, and initial Troponin) score to make decisions about admission, observation, or discharge in patients presenting to the emergency department (ED) with chest pain. However, hesitance to refrain from admitting and testing patients with low scores could explain its small effect on health care costs seen in this analysis. The study is published in Annals of Internal Medicine.

About 80 percent of patients with chest pain have an underlying condition that is noncardiac and not life threatening and, therefore, could be managed further in an outpatient setting. However, Western medicine is conservative and two-thirds of patients are admitted and receive additional testing. This puts a large burden on the health care system. Utilizing a risk-stratification tool, like the HEART score, could reduce this burden but its safety in daily practice has not yet been determined.

To measure the effect of utilizing the HEART score in daily practice, researchers at University Medical Center in Utrecht, the Netherlands studied outcomes on unselected patients with chest pain presenting at EDs in 9 Dutch hospitals in 2013 and 2014. The researchers utilized a stepped-wedge, cluster randomized trial design, which involves a sequential but random rollout of an intervention over multiple time periods. A total of 3,648 patients were included in the analysis (1,827 patients received usual care and 1,821 received HEART care). All hospitals started with usual care and then every 6 weeks one hospital was randomly assigned to switch to HEART care.

At 6 weeks, the proportion of patients with major adverse cardiac events was 1.3 percent lower in the HEART care group than in usual care (after correction for potential confounders and clustered data). The 1-sided upper confidence limit was +2.0%, not exceeding the pre-specified margin of non-inferiority. There were no statistically significant differences seen in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners. Use of health care resources was typically lower during HEART care, but absolute differences were small, and no statistically significant differences were found after adjustment for clustering and time steps. Hesitance to rely on the score could contribute to the small effect on health care costs. But extrapolation of the findings of a cost-effectiveness analysis (including nonadherence) suggests that HEART care could lead to annual savings of €40 million in the Netherlands.

2. Mindfulness offers brief, but clinically insignificant relief from low back pain

Abstract: http://annals.org/aim/article/doi/10.7326/M16-1997

Mindfulness-based stress reduction, a practice which may include various forms of meditation and physical exercise, is associated with short-term improvements in pain and function for people suffering from low back pain. However, compared to usual care, mindfulness-based stress reduction was not associated with significant differences in short- or long-term outcomes. A systematic review and meta-analysis is published in Annals of Internal Medicine.

Low back pain is a major public health problem for which optimal clinical treatment yet to be identified. As such, patients often seek complementary therapies. Mindfulness-based stress reduction is frequently used to treat pain-related conditions, but the effect of this approach on low back pain is not clear.

Researchers at University of Duisburg, Essen, Germany reviewed seven randomized controlled trials involving 864 patients with low back pain to assess the efficacy and safety of mindfulness stress reduction on pain and physical function. Most of the mindfulness interventions included in the analysis were adapted from a mindfulness-based stress reduction program that was developed at the University of Massachusetts. The intervention involves an 8-week structured program of weekly 2.5 hour group sessions and an all-day (7- to 8-hour) silent retreat. Key components include sitting meditation; walking meditation; hatha yoga and body scan; and sustained mindfulness practice, a practice in which attention is sequentially focused on all different parts of the body.

The literature showed that a mindfulness-based stress reduction intervention may be associated with short-term improvement in pain intensity and physical functioning compared with usual care, but the difference is neither clinically meaningful, nor sustained in the long term. The researchers noted that not all of the interventions included yoga, which has been shown to increase function and decrease disability in patients with low back pain. They suggest that future studies should examine the effects of components of mindfulness-based stress reduction interventions, such as mindful meditation and yoga.

3. Waist circumference, not BMI, a stronger predictor of death risk

Abstract: http://annals.org/aim/article/doi/10.7326/L17-0022

People with a normal BMI who carry their weight around the middle are at the highest risk for death from any cause compared to those who are overweight or obese but carry their weight elsewhere. These findings are consistent with recent studies examining all-cause mortality. The observational study is published in Annals of Internal Medicine.

Various studies have examined whether central obesity, or waist circumference, can predict death risk over and above BMI. In a recent study of 15,184 adults, normal-weight individuals with central obesity had the worst long-term survival, even when compared to overweight and obese participants with central obesity. Researchers at Loughborough University, United Kingdom, and University of Sydney, Australia sought to replicate these analyses in a larger general population sample of adults.

The researchers recruited 42,702 participants from 10 survey years of the Health Survey for England and the Scottish Health Survey. The participants were measured and categorized as normal weight; normal weight with central obesity; overweight; overweight with central obesity; obese; or obese with central obesity based on BMI and waist-hip ratio. The researchers found that when compared with the normal weight participants without central obesity, only normal weight and obese persons with central obesity were at increased risk for all-cause mortality. All participants with central obesity, regardless of BMI, were at increased risk for cardiovascular deaths.

The researchers conclude that these findings are relatively consistent with previous studies. The paradoxical findings in overweight and obese persons, even in the presence of central obesity, are difficult to explain. The authors note that the study relied on a single clinical assessment and weight histories may have been more informative.

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