EBM demonstration

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EBM demonstration

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Clinical Problem

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PICO

• Patient ????????
• Intervention ???????????
• Comparison ??????
• Outcome ?????

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• Patient
• Stroke patients
• Intervention
• Anti-coagulation

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That will go WRONG !

• Comparison (?????)
• Standard treatment Anti-platelet
• Unclear Placebo
• Outcome (????)
• Morbidity vs Mortality
• Long term prognosis
• Recurrent rate ?
• ADF ?
• Complication rate ?
• Co-morbidity ?
• .

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  ?

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Show Me the PICO !!

• Patient Stroke
• Intervention Anti-coagulation
• Comparison Anti-Platelet
• Outcome Recurrent rate

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???????

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• Guideline
• EBM Reviews
• Pubmed
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DatabasesOrz
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that may go WRONG !!

• Search priority
• Key words
• Broaden? Narrow?
• Expressions

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Key Words

• Shift the WORDs
• Aspirin ltgt Antiplatelet
• Coumadin ltgt Anticoagulation
• Stroke ltgt CVA
• DO NOT Use shortcuts

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Guideline

• National Clearing House
• www.GUIDELINE.gov
• www.NGC.org
• Always search for published guidelines
• A guideline is any document that aims to
  streamline particular processes according to a
  set routine

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Guideline
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Guideline

• 33 hits
• 5 Selected

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EBM Reviews

• Cochrane Review Groups
• ACP Journal Club
• UpToDate
• POEMS

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ACP Journal Club
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ACP Journal Club
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ACP Journal CLUB
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ACP Journal Club
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ACP Journal CLub

• 12 hits,
• 4 selected

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Cochrane Review Group
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Cochrane Library
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Cochrane Library
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Cochrane Review Group

• 33 hits
• 5 selected

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• ????? Level of Evidence
• NNT NNH (Number Needs to Treat)
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Conclusions

• Long-term anticoagulation may be more effective
  than antiplatelet treatment for preventing
  nonfatal stroke but not other vascular events in
  patients with nonrheumatic AF.
• In patients with acute ischemic stroke,
  anticoagulants used alone or with antiplatelet
  agents are not superior to antiplatelet agents
  used alone.
• There is no evidence that stroke patients with a
  normal heart rhythm benefit from anticoagulants.

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Abstracts Cochrane Review

• In most ischaemic strokes, the blockage is caused
  by a blood clot. Anticoagulant drugs, such as
  warfarin, may prevent such clots forming and
  hence could prevent stroke. However,
  anticoagulant drugs may also cause bleeding in
  the brain and this complication could offset any
  benefits. This review identified a number of
  trials, in patients who had had a stroke, of
  anticoagulants to prevent further strokes. There
  was good evidence that anticoagulants could cause
  serious bleeding, and there was no evidence that
  anticoagulants were of benefit. However, other
  trials show that patients with an irregular
  heartbeat (atrial fibrillation) and a recent
  stroke due to a blocked artery do benefit from
  anticoagulants. New trials are underway to see
  whether stroke patients with a normal heart
  rhythm can get greater benefit from
  anticoagulants than from standard clot-preventing
  treatments such as aspirin and other antiplatelet
  drugs.

P Sandercock, O Mielke, M Liu, C Counsell
Anticoagulants for preventing recurrence
following presumed non-cardioembolic ischaemic
stroke or transient ischaemic attack. 2003
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Clinical Applications

• Prevention of Noncardioembolic Cerebral Ischemic
  Events Oral Anticoagulants
• For most patients with noncardioembolic stroke or
  TIA, the guideline developers recommend
  antiplatelet agents over oral anticoagulation
  (Grade 1A).
• For patients with well-documented prothrombotic
  disorders, the guideline developers suggest oral
  anticoagulation over antiplatelet agents (Grade
  2C).

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Clinical Applications

• Patients with Stroke with Underlying Atrial
  Fibrillation Antiplatelet Agents
• For patients with cardioembolic stroke who have
  contraindications to anticoagulant therapy, the
  guideline developers recommend aspirin (Grade 1A).

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Clinical Applications

• Patients with Aortic Atheromata
• In patients with stroke associated with aortic
  atherosclerotic lesions, the guideline developers
  recommend antiplatelet therapy over no therapy
  (Grade 1C). For patients with cryptogenic stroke
  associated with mobile aortic arch thrombi, the
  guideline developers suggest either oral
  anticoagulation or antiplatelet agents (Grade 2C).

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Clinical Applications

• Patients with Patent Foramen Ovale (PFO)
• In patients with cryptogenic ischemic stroke and
  a patent foramen ovale, the guideline developers
  recommend antiplatelet therapy over no therapy
  (Grade 1C), and suggest antiplatelet agents over
  anticoagulation (Grade 2A).

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Clinical Applications

• Mitral Valve Strands and Prolapse
• In patients with mitral valve strands or
  prolapse, who have a history of TIA or stroke,
  the guideline developers recommend antiplatelet
  therapy (Grade 1C).

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Key Point

• Guideline or System Reviews are favoured
• Clinical Application
• Conclusion
• Critically appraisal for the result of Pubmed
  Search
• Guideline and SRs are NOT AVAILABLE

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APP Pubmed Search
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APP Pubmed Search
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The Patient Profile

• Does he meet the following criterias?
• Prothrombic conditions
• Atrial fibrillations
• Aortic Atheromata, and the stroke was highly
  suspected to relate with