"For example, the rule assumes you’ve already checked for hypoglycemia, a common cause of syncope," the hospitalist explained.
The San Francisco Syncope Rule is available in app form as Doctor Tools of the Trade.
Atrial fibrillation: To anticoagulate or not? This is a decision that entails balancing the reduction in stroke risk obtained with anticoagulation against the potential harm in the form of bleeding. The best tool for assessing the potential stroke-risk benefit is the CHA2DS2-VASc score, which represents a significant advance over the CHADS2 score, in Dr. Burke’s view.
"What the CHA2DS2-VASc score is really useful for, I think, is in putting people into low- or high-risk buckets. It takes people out of that intermediate-risk category in CHADS2," he explained.
It turns out that when physicians rely upon clinical intuition to estimate the risk of clinically important bleeding in patients on oral anticoagulation, they tend to overestimate the true risk. This observation has led to a proliferation of scales aimed at predicting who is likely to bleed when placed on warfarin. The best performer among them, regardless of whether the endpoint is any clinically relevant bleeding, major bleeding, or all-cause mortality, is the HAS-BLED score.
"I would encourage you to use both the CHA2DS2-VASc and HAS-BLED, and to use them at the same time. In some cases you’ll find the numbers are really discordant; there may be much more benefit than you thought, or much more risk," Dr. Burke said.
The focus-AF calculator is the app that will do the work.
Risk stratification after TIA or stroke. The ABCD2 score provides an estimate of stroke risk within 7 or 90 days after a TIA. This information helps establish the urgency of patient evaluation and risk factor management. A patient with an ABCD2 score of 4 or more should go straight to the emergency department, while a score of 3 or less indicates outpatient evaluation is appropriate. The Neuro Toolkit app will run the numbers.
Dr. Burke is keeping a watchful eye on a number of other clinical decision rules that, while promising, aren’t quite ready for prime time in his view. These include the FRAX score, the TIMI score, and the Marburg Heart Score. The Marburg score, for example, has been extensively validated as a tool to help primary care physicians decide whether chest pain is cardiac or noncardiac. But in the clinical trials, the score wasn’t compared to clinical intuition. That’s a problem.
"I think our clinical intuition here is relatively good. So I’d like to see data showing the rule adds something to clinical intuition before I recommend it," he said.
In a head-to-head comparative trial, the Pittsburgh Knee Rule outperformed the older Ottawa Knee Rule as an aid in figuring out who needs imaging after a knee injury. Impressive, in Dr. Burke’s view, but he’d like to see the results confirmed in a second study.
He reported having no financial conflicts.