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

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Clinical Scenario （臨床情境） 82-year-old woman with history of atrial fib

rillation, 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.

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Clinical Uncertainty → PICO 問題

In patient with atrial fibrillation, could wafarin treatment prevent stroke?

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臨床個案的 PICO

Patient / Problem patient with atrial fibrillation

Intervention warfarin tretment

Comparison placebo

Outcome stroke event

Type of Question: Therapy

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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[P

ublication 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

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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,

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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.

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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）

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The Study: （研究效度） - 3本篇文獻的 PICO (T)

Patient / Problem

Patient with atrial fibrillation

Intervention Warfarin/aspirin

Comparison placebo

Outcome Warfarin reduced primary events by 67%

Time 2 years(spirin), 3years(warfarin)

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The Evidence: （研究重要結果） - 1

Follow-up

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The Evidence: （研究重要結果） - 2

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The Evidence: （研究重要結果） - 3

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The Evidence: （研究重要結果） - 4

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The Evidence: （研究重要結果） - 5

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The Evidence: （研究重要結果） - 6

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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 patient

s 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

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回到臨床個案情境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

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References: 1: Coron Artery Dis. 1998;9(4):223-Warfarin red

uces 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

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結 論 （標題 Title ）Stroke risk stratification to identify high-risk

patients with atrial fibrillation who warrant lifelong anticoagulation

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