與應(yīng)用陳進(jìn)療性研究文獻(xiàn)評(píng)價(jià)OA75-year-oldman,afterbeingdischargedfromhospital2weekspreviouslycarotidendarterectomyaftersufferingatransientischemicattack(TIA)metoprolol(50mgBid)forhypertensionandaspirin81mgdailyOToday,hehasbroughtusanarticlefromtheInternetdescribingthebenefitsofstatinsforstrokepreventionheshouldtakeitOHislastvisitshowedterectomyhypertensionandnormalpidprofiledoestherapywithastatineaseriskofstrokepidprofile StudiesCochraneCentralRegistryofControlledTrials↓↓ms↓ ↓↓↓↓*WesometimesincludeasearchofEBOCatthisstage,butwemustbearinmindthatithasn’↓ ↓↓↓↓OAperfectevidence-basedclinicalinformationsystemrelevantandimportantresearchevidenceaboutaclinicalproblemmedicalrecord,aspecificpatient’scircumstancestotherelevantinformation.Onosystematicreviewscomparingstatinsornon-statincholesterolloweringtreatmentsversusplacebothatreportedresultsseparatelyforpeoplewithpreviousstrokeortransientischaemicattack.OOnesystematicreviewfoundthatstatinsreducedmajorvascularevents,includingstroke,comparedwithplaceboornotreatmentinvariousdifferenttypesofpeople,includingthosewithpriorischaemicstrokeortransientischaemicattack,irrespectiveofbaselinecholesterolorofthepresenceorabsenceofcoronaryarterydisease.OOnesystematicreviewandthreeadditionalRCTsinbroaderpopulationsfoundthatnon-statincholesterolloweringdrugtreatmentsdidnotreducestrokecomparedwithplaceboornotreatment.Statinsversusplacebo:2003,26RCTs,97981people),whichassessedtheeffectofstatinsonstrokeinpeoplewithcoronaryheartdisease,raisedandnormalcholesterollevels,diabetes,priorischaemicstrokeortransientischaemicattack(TIA),andtheelderly.[40]rpeoplewithapreviousischaemicstrokeorTIA.OThereviewfoundthatstatinssignificantlyreducedstrokecomparedwithplaceboornotreatmentafterameanof4.3years(1285/47090[2.7%]withstatinsv1605/47038[3.4%]withcontrol;OR0.79,95%CI0.73to0.85).[40]nstrokewascloselyassociatedwiththereductioninlowdensitylipoprotein(LDL)-cholesterolsuchthateach10%reductioninLDLcholesterolreducedtheriskofstrokebyabout]peopleconductedasubgroupanalysisinpeoplewithpriorischaemicstrokeorTIA.OThesubgroupanalysisfoundthatsimvastatinsignificantlyreducedmajorvascularevents(majorcoronaryevents,strokes,andcoronaryornon-coronaryrevascularisations)comparedwithplaceboafter5years'followup(24.7%withsimvastatinv29.8%withplacebo;RR0.80,95%CI0.71to0.92).vasculareventsfortheother17256peopleinthetrial,andoccurredirrespectiveofthepresenceorabsenceofknowncoronarydisease.[41]significantlyreducetheriskofstrokecomparedwithplaceboinpeoplewithpriorstrokeorTIA(RR0.98,95%CI0.79to1.22),butthisretrospectivesubgroupanalysiswasnotsupportedbythedefinitebenefitobservedintheprespecifiedanalysisofmajorvasculareventsinpeoplewithapriorstrokeorTIA.[41]Statinsversusplacebo:OOnesystematicreviewfoundnosignificantdifferencebetweenstatinsandplaceboinhaemorrhagicstroke(0.32%withstatinsv0.36%withplacebo;OR0.90,95%CI0.65to1.22).[40]OAnothersystematicreview(35000peopleand158000personyearsofobservation)foundnosignificantdifferenceinoveralladverseeffectsbetweenstatinsandplacebo(48RCTs;1063/14197[7.5%]withstatinsv923/10568[8.7%]withplacebo;ARR+1%,95%CI–1%to+3%).[45]reportedineightpeopletreatedwithstatinsandfivepeoplewithplacebo(nofurtherdatareported).ONocasesofliverfailurewerereportedinanyoftheRCTs.ORaisedserumcreatinekinaselevels(≥10timestheupperlimitofnormal)werereportedin55people(0.17%)withstatinsand43people(0.13%)withplacebo,Owithmusclesymptomsreportedby13peoplewithstatinsandfourpeoplewithplacebo(nofurtherdatareportedforeitheroutcome).ORaisedalanineaminotransferaselevels(≥3timesupperlimitofnormal)werereportedin449people(1.3%)withstatinsand383people(1.1%)withplacebo(nofurtherdatareported).[45]Clinicalguide:OThesystematicreviewfoundthat,overall,cholesterolloweringusingstatinsornon-statinssignificantlyreducedmortalityandfatalcoronaryheartdiseasecomparedwithplaceboornotreatment(mortality:OR0.85,95%CI0.76to0.93;fatalcoronaryheartdisease:OR0.79,95%CI0.74to0.85).[4]OAnothersystematicreviewfoundthattherelativeriskreductionofstrokeandofischaemicheartdiseaseeventswasproportionaltothesizeofthereductioninLDL-cholesterol;foreach1.0mmol/litrereductioninLDL-cholesterol,theriskofstrokewasreducedbyaboutafifth,withsmallerreductionsinthefirst2yearsoftreatment.[45]artdiseaseeventswasreducedbyaboutathirdwith3–5yearsoftreatment,withmuchsmallerreductionsinthefirst2yearsoftreatment.[45]thattherelativereductioninmajorvasculareventswassimilaramongthosepeoplewithdifferentpretreatmentconcentrationsofcholesterolandtriglycerides,inallagegroupsincluded,andirrespectiveofapriorhistoryofcoronaryarterydisease,ischaemicstrokeorTIA,ischaemicheartdisease,peripheralarterialdiseaseordiabetes.[46]in4700peoplewithminorstrokeorTIAisinprogress.[47]fromallRCTsofcholesterolreductionaimstosummarisetheeffectsofreducingcholesterolindifferentgroupsofpeople,includingthosewithpreviousstrokeorTIA.[48]suggestedthatcholesterolreductiondecreasesischaemic,butnothaemorrhagic,stroke.[3]ResearchGroupBloodpressurecholesterolandniGCholesterolreductionandstrokeoccurrenceanoverviewofrandomizedaltrialsCerebrovascDisSearchdatenotreportedprimarysourcesnotreportedPubMed3.AmarencoP,LabreucheJ,LavalléeP,etal.Statinsinstrokepreventionandcarotidatherosclerosis.SystematicreviewanduptodatemetaanalysisStroke2902–2909.dyCollaborativeGroupEffectsofcholesterolloweringwithsimvastatinonstrokeandotherventsinpeoplewithcerebrovasculardiseaseorotherhighriskconditionsLancet[PubMed]5.Anonymous.Thetreatmentofcerebrovasculardiseasewithclofibrate.FinalreportoftheVeterans'AdministrationveStudyofAtherosclerosisneurologysectionStrokePubMedllinsDetalGemfibrozilforthesecondarypreventionofcoronaryheartdiseaseinmenwithlowlevelsofhighdensitylipoproteincholesterolNEnglJMedPubMedTheBIPStudyGroup.SecondarypreventionbyraisingHDL-cholesterolandreducingtriglyceridesinpatientswithonaryarterydiseaseTheBezafibrateInfarctionPreventionBIPStudyCirculationPubMedantifyingeffectofstatinsonlowdensitylipoproteincholesterolischaemicchraneLibraryandWebofSciencedatabasesPubMedborativeGroupMRCBHFHeartProtectionStudyofcholesterolloweringwithhighriskindividualsarandomisedplacebocontrolledtrialLancetPubMeddsearchstringatorvastatinlastaccessedFebruary2006).CholesterolTreatmentTrialistsCollaborationProtocolforaprospectivecollaborativeoverviewofallcurrentand2S:SynopsesOSynopsesofindividualstudiesandreviewsarethenextbestsource.OACPJournalClubOACP-stroke.txtOACP-stroke1.txtOACP-stroke.docOtheCochraneLibrarydatabasesofsystematicreviewsOOvid’sEBMROMEDLINE:non-Cochranesystematicreviews.OstrokeSR.pdfOstrokeSR1.pdfOMRC.pdfO1a:SystematicreviewwithhomogeneityofRCTsO1b:IndividualRCTwithnarrowconfidenceintervalO2levelO2a:Systematicreview(withhomogeneity)ofcohortstudiesO2b:Individualcohortstudy(includinglow-qualityRCT;e.g.<80%follow-up)O3levelO3a:Systematicreview(withhomogeneity)ofcase–controlstudyO3b:Individualcase–controlstudyO4levelOCaseseries(andpoorqualitycohortandcase–controlstudies)O5levelOExpertopinionwithoutexplicitcriticalappraisal,orbasedon physiology,benchresearchor“firstprinciples”O(jiān)MRC/BHFHeartProtectionStudy.Lancet2002;360:7–22.OReadthearticleanddecide:OAretheresultsofthistherapyarticlevalid?OArethevalidresultsofthistherapystudyaboutthistherapyincaringforourpatient?Yes.ReferstoanotherYes.Referstoanotherarticlethatdescribesthemethodsmorefully.NotethatinACPJournalClubitmentionedthatallocationwasconcealed.Yes.patientstotreatmentsrandomized?Wastherandomizationlistconcealed?>99%follow-upata>99%follow-upatameanof5years.sufficientlylongandcomplete?Wereallpatientsanalyzedinthegroupstowhichtheywererandomized?Anintentiontotreatanalysiswascompleted.Werepatients,cliniciansandstudypersonnelkept“blind”totreatment?Yes.Participants,clinicians,datacollectorsandoutcomesassessorswereblinded.Werethegroupstreatedequally,apartfromtheexperimentaltreatment?Yes.Werethegroupssimilaratthestartofthetrialapartfromtheexperimentaltherapy?Yes.Whatisthemagnitudeofthetreatmenteffect?Howpreciseistheestimateofthetreatmenteffect?StrokeRelativeriskreductionAbsoluteriskreductionNumbereededtotreatNNTERCER?EERERCER?EER7%4.3%95%CIDotheseresultsapplytoourpatient?IsourpatientsodifferentfromDotheseresultsapplytoourpatient?Isourpatientsodifferentfromthoseinthestudythatitsresultscannotapply?Isthetreatmentfeasibleinoursetting?No.Includespatients40–80yearsoldwithTIA,carotidendarterectomyandnormallipidprofiles.Yesitisavailablebutmustexplorewithpatientifheiswillingtotakeit.Whatareourpatient’spotentialbenefitsandharmsfromtheNNTNNH0)=70Areourpatient’svaluesandpreferencessatisfiedbytheregimenanditsconsequences?Doweandourpatienthaveaclearassessmentoftheirvaluesandpreferences?Needtoexplorewithpatient.Aretheymetbythisregimenanditsconsequences?Needtoexplorewithpatient.SYSTEMATICREVIEWOstrokeSR1.pdfalsYes.sitdescribeacomprehensiveanddetailedsearchorrelevanttrialsYes.ndividualstudiesassessedforvalidityMost.4