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EBM Journal ClubTai Chi & Heart Failure
2013.01.28R2 張宇涵
指導者：陳星諭醫師
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Heart Failure
• Definition
• Clinical syndrome
• Structural or functional abnormalities
• Metabolic demand impairment
• Progressively, High M & M
Heart Failure, Cardiomyopathy, and Valvular Heart Disease. The Washington Manual of Medical Therapeutics, 33rd Ed. 4
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Classifications5
Hunt SA et al. Circulation. 2001;104:2996-3007. Farrell MH et al. JAMA. 2002;287:890-897.
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Treatment
• Medications
• ACEi/ARB
• Diuretics
• β-blocker
• Aldosterone antagonists
• Nitrates & Hydralazine
• Digoxin
• Inotropic agentsHeart Failure, Cardiomyopathy, and Valvular Heart Disease. The Washington Manual of Medical Therapeutics, 33rd Ed.
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Treatment
• Non-medications
• Coronary revascularization
• Cardiac resynchronization therapy or biventricular pacing
• ICDs
• IABPs
• Ventricular assist devices
• Cardiac transplantation
Heart Failure, Cardiomyopathy, and Valvular Heart Disease. The Washington Manual of Medical Therapeutics, 33rd Ed. 7
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Treatment
• Other treatment
• Lifestyle modifications
• Minimization of medications
• Oxygen supplement
• Sleep apnea treatment
Heart Failure, Cardiomyopathy, and Valvular Heart Disease. The Washington Manual of Medical Therapeutics, 33rd Ed. 8
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Five Steps to Practice EBM
• Asking an answerable question（問）
• Tracking down the best evidence（查）
• Critical appraisal（讀）
• Integrating the appraisal（用）
• Evaluation （審）
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Asking
• Four components
• Patients
• Intervention
• Comparison
• Outcome
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Searching12
From Dr. Joseph F Smith Medical Library
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Searching13
From 林口長庚實證醫學中心
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Critical Appraisal
• Validity
• Chance, Bias
• Impact
• NNT, NNH
• Practice applicability
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Clinical Scenarios
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Scenarios
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Asking
• Patients
• Patient with Heart failure
• Interventions
• Tai chi
• Comparison
• Conventional treatments
• Outcome
• Prognosis
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Acquiring
• Database
• EBM - All
• Pubmed
• Clinical queries
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Keywords
• Heart failure [text]
• Tai chi [text]AND
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Journal Citation Report : Science Edition29
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Validity
• Clinical Appraisal Tool (CAT)
• CEBM - University of Oxford
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Critical Appraisal Sheets from CEBM, University of Oxford32
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Critical Appraisal Sheets from CEBM, University of Oxford33
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Critical Appraisal Sheets from CEBM, University of Oxford35
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Critical Appraisal Sheets from CEBM, University of Oxford36
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Critical Appraisal Sheets from CEBM, University of Oxford38
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Critical Appraisal Sheets from CEBM, University of Oxford39
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Critical Appraisal Sheets from CEBM, University of Oxford41
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Critical Appraisal Sheets from CEBM, University of Oxford42
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Critical Appraisal Sheets from CEBM, University of Oxford45
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Critical Appraisal Sheets from CEBM, University of Oxford46
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Critical Appraisal Sheets from CEBM, University of Oxford48
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Critical Appraisal Sheets from CEBM, University of Oxford49
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Evaluation
• Primary outcome
• Exercise capacity• 6 mins walk test
• Disease specified QoL• Minnesota Living With Heart Failure Questionnaire(MLHF)
• Secondary outcome
• NT-proBNP
• Blood pressure
• Peak oxygen uptake (peak V02)
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Primary outcome
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Exercise Capacity53
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Quality of Life54
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Secondary outcome
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NT pro-BNP56
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Systolic BP57
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Diastolic BP
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Peak Oxygen uptake59
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Discussion
• Improved in QoL
• The reason of non-significance
• Cause of heterogeneity
• Low cost and no adverse effect
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Limitations
• Other objective measurement
• LV function, muscle strength, Survival
• Other exercise performance
• walking, conventional treadmill, bicycle ergometer exercise
• Small sample size
• Better study design needed
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Conclusion
•Tai chi may improve quality of life, but does not appear to increase exercise capacity in patient with heart failure.(Level I[high-level] evidence)
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Outline
• Heart failure reviews
• EBM concepts
• Clinical Scenarios
• Asking
• Acquiring
• Appraisal
• Apply
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Return to Clinical Scenario
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References• Pan L, Yan J, Guo Y, Yan J. Effects of Tai chi training on exercise capacity and quality of life
in patients with chronic heart failure: a meta-analysis. Eur J Heart Fail. 2012 Oct 25. [Epub ahead of print]
• Barrow DE, Bedford A, Ives G, O’Toole L, Channer KS. An evaluation of the effects of tai chi chuan and chi kung training in patients with symptomatic heart failure: a randomised controlled pilot study. Postgrad Med J 2007;83:717–721.
• Caminiti G, Volterrani M, Marazzi G, Cerrito A, Massaro R, Arisi A, Franchini A,Sposato B, Rosano G. Tai chi enhances the effects of endurance training in the rehabilitation of elderly patients with chronic heart failure. Rehabil Res Pract2011;2011:761958.
• Yeh GY, Wood MJ, Lorell BH, Stevenson LW, Eisenberg DM, Wayne PM, Goldberger AL, Davis RB, Phillips RS. Effects of tai chi mind–body movement therapy on functional status and exercise capacity in patients with chronic heart failure: a randomized controlled trial. Am J Med 2004;117:541–548.
• Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Forman D, Davis RB, Phillips RS. Tai chi exercise in patients with chronic heart failure: a randomizedclinical trial. Arch Intern Med 2011;171:750–757
• Brian R. Lindman, Stacy A. Mandras, Benico Barzilai, Susan M. Joseph, and Gregory A. Ewald: Heart Failure, Cardiomyopathy, and Valvular Heart disease. The Washington Manual of Medical Therapeutics, 33rd Ed. P.155-166.
• Critical Appraisal Sheets from CEBM, University of Oxford
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Thanks for your attention!
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