Stress testing for patients with low-risk chest pain and use of venous thromboembolism chemoprophylaxis in low-risk patients are the latest practices to come under scrutiny and were discussed during a special session at HM19.
Dr. Anthony Breu
Anthony Breu, MD, a hospitalist and director of resident education in the Veterans Affairs Boston Healthcare System, presented “common practices that have low or no value.” He provided arguments against these practices based in both evidence and pathophysiology.
“Things We Do For No Reason: The 2019 Clinical Update for Hospitalists,” presented Tuesday morning, was the latest in a series of such sessions held during SHM’s Annual Conference. Leonard S. Feldman, MD, SFHM, from Johns Hopkins Medicine in Baltimore, presented the first “Things We Do For No Reason” session at the 2012 conference in San Diego, analyzing the 30% target hematocrit for cardiac patients, naso-gastric lavage in gastrointestinal bleeds, fractional excretion of sodium and urea in evaluating acute kidney injuries, and the use of daily chest x-rays in ICUs.
“For patients with low-risk chest pain, stress tests do not add value,” said Dr. Breu. There are a number of ways a hospitalist can determine whether a patient has low-risk chest pain, and the rates of acute MI and mortality at 30 days are “well below 1%” for these patients, he noted.
“Stress tests may lower this rate a bit, but they are unfortunately unable to identify all patients who will experience subsequent events,” he said. “Also, given that pretest probability of coronary artery disease is low in these patients, the false-positive rate approaches 50%.”
Dr. Breu attributed the continued use of stress tests in patients with low-risk chest pain to recent American College of Cardiology and American Heart Association statements on appropriate use of stress testing, which should occur during initial hospitalization or within 72 hours of discharge. In addition, many hospitalists believe a negative stress test result can help them rule out a diagnosis like coronary artery disease.
In a second example of suspect practices, the need for venous thromboembolism (VTE) chemoprophylaxis, such as with subcutaneous enoxaparin, in high-risk patients is based on evidence that shows a reduction in asymptomatic deep vein thrombosis (DVT). However, “the evidence is not as clear” on whether VTE chemoprophylaxis reduces symptomatic DVT or pulmonary embolism (PE), Dr. Breu said.
“When this is coupled with the fact that bleeding is increased with chemoprophylaxis, its use in low-risk patients should be avoided,” Dr. Breu said. “Unfortunately, there is evidence that many of us administer VTE prophylaxis to low-risk patients just as often as we do for high-risk patients.”
Dr. Breu said he suspects many providers “overestimate the benefits” of VTE chemoprophylaxis. “I suspect that if someone is on the fence about whether to administer VTE [chemoprophylaxis], many err on the side of administering, fearing that they will miss an opportunity to prevent a DVT or PE while not realizing the risk of bleeding is real.”
Dr. Breu presented evidence from the literature as support for his argument against the practice of ordering stress tests and administering VTE chemoprophylaxis in low-risk patients. The oldest study goes back to 1967, while the most recent study was published in February 2019, he said.
“My hope is that attendees will be less inclined to order stress tests in patients with low-risk chest pain,” Dr. Breu said in an interview. “I also hope that they will apply scoring systems to better identify patients who are at high risk for VTE and not administer chemoprophylaxis to all others.”
Dr. Breu reported having no relevant financial disclosures.