ㄧ般內科 實 證 期 刊 閱 讀 報 告 EBM-style Journal Reading

1. ㄧ般內科實 證 期 刊 閱 讀 報 告EBM-style Journal Reading 報告人：蔡杰璋 Email: zeisstsai@hotmail.com 指導臨床教師：何昌益 日期：2009/4/30 地點：ㄧ般內科醫研室

2. Clinical Scenario （臨床情境） • 82-year-old woman with history of atrial fibrillation, heart failure, CAD s/p PCI, type II DM, hypertension, chronic kidey disease and hyperlipidemia . • She was admitted for consiousness drowsy, and emotion incontinence was noted in the ward. The brain MRI revealed acute ischemia infarction.

3. Clinical Uncertainty → PICO 問題 • In patient with atrial fibrillation, could wafarin treatment prevent stroke?

4. 臨床個案的PICO Type of Question: Therapy

5. Search Terms & Strategy:（搜尋關鍵字與策略） • 資料庫： PubMed • 搜尋日期： 980420 • 搜尋關鍵字與隅策略： • #4 Search (#1)and(#2)and(#3) • #2 Search (atrial fibrillation) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) • #1 Search (warfarin) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) • #3 Search (cerebral ischemia) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) • Field: Title/Abstract 共17篇

6. Best available evidence:（挑選可獲得之最佳研究證據） • Citation/s:Ann Intern Med. 2003;138:831-838. Lessons from the Stroke Prevention in Atrial Fibrillation Trials • Lead author's name : Robert G. Hart, MD; Jonathan L. Halperin, MD; Lesly A. Pearce, MS; David C. Anderson, MD; Richard A. Kronmal, PhD; Ruth McBride, BS;Elaine Nasco, BA; David G. Sherman, MD; Robert L. Talbert, PharmD; and John R. Marler, MD,

7. The Study: （研究效度）- 1 • The Stroke Prevention in Atrial Fibrillation (SPAF) studies, sponsored by the National Institute of Neurological Disorders and Stroke, consisted of six multicenter clinical trials assessing antithrombotic therapies for preventing stroke in patients with nonvalvular atrial fibrillation.

8. The Study: （研究效度）- 2 • The trials involved 3950 participants followed for 7100 patientyears,during which 247 participants had strokes; collectively, • Level of Evidence: 5（屬於review 文章）

9. The Study: （研究效度）- 3本篇文獻的PICO (T)

10. The Evidence: （研究重要結果）- 1 • Follow-up

11. The Evidence: （研究重要結果）- 2

12. The Evidence: （研究重要結果）- 3

13. The Evidence: （研究重要結果）- 4

14. The Evidence: （研究重要結果）- 5

15. The Evidence: （研究重要結果）- 6

17. Comment & Discussion: -1 • Warfarin reduces stroke more than aspirin for all patients with atrial fibrillation, yet many patients do not benefit substantially from anticoagulation. Large benefits of adjusted-dose warfarin accrue to selected high-risk patients with atrial fibrillation, while low-risk patients who do not benefit importantly from anticoagulation over aspirin can be identified. • Stroke risk stratification to identify high-risk patients with atrial fibrillation who warrant lifelong anticoagulation has been investigated by the SPAF Investigators

18. Clinical bottom line 臨床決策底線 Stroke risk stratification to identify high-risk patients with atrial fibrillation who warrant lifelong anticoagulation has been investigated by the SPAF Investigators 回到臨床個案情境

19. References: • 1: Coron Artery Dis. 1998;9(4):223-Warfarin reduces silent cerebral infarction in elderly patients with atrial fibrillation.Matsuo S, Nakamura Y, Kinoshita M. First Department of Internal Medicine, Shiga University of Medical Science, Japan. • 2 :Neurology. 1998 Sep;51(3):674-81.Links Prevention of stroke in patients with nonvalvular atrial fibrillation.Hart RG, Sherman DG, Easton JD, Cairns JA.University of Texas Health Science Center, San Antonio 78284-7883

20. 結 論 （標題 Title） Stroke risk stratification to identify high-risk patients with atrial fibrillation who warrant lifelong anticoagulation

21. 敬請指教