The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied at an interpretation that will help clinicians levy evidence into practice. Glenn Griffin, MD not aways a clinical scenario and question based forward the Cochrane Abstract, along with the evidence-based answer and a replete critique of the abstract.

This clinical satisfaction conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical contentment presented with practice recommendations supported from evidence that has been systematically reviewed through an AAFP-approved source. The practice recommendations in this activity are available at www.update-software.com/ abstracts/ab003242.htm.

Clinical Scenario

Your mother-in-law just had a calamity and the computed tomographic scan displays no evidence of hemorrhage. The neurologist in the urgency department is debating whether to use heparin or aspirin for treatment.

Clinical Question

Should aspirin, warfarin, or heparin be used to treat acute ischemic stroke?

Evidence-Based Answer

Aspirin has a small benefit for long-term consequence and survival. Anticoagulants increase the risk for bleeding and do not have long-term benefit.

Cochrane Critique

Did the authors address a focused clinical question? Yes

Were the criteria used to choice articles for inclusion appropriate? Yes

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes

Were the assessments of studies reproducible? Yes

Were the ensues similar from study to study? Yes

for what reason precise were the results? surpassingly precise.

Can the ends be applied to patient care? Yes

Do the conclusions make biologic and clinical sense? The conclusions make thinking principle from a biologic and clinical point of view, and the benefits, harms, and richnesss favor the use of antiplatelet agents for all of the important outcomes

Practice Pointers

The participants in this review were patients who had sustained an ischemic stroke within 48 hours of being randomized for entrance into the trial. The interventions included unfractionated or low-molecular-weight heparin, aspirin plus heparin, and aspirin alone.

The authors studied many results including death or dependency at the extreme point of follow-up, death from any cause during follow-up death from any cause during treatment, silent or symptomatic DVT symptomatic pulmonary embolus during treatment, progression of symptoms during treatment, returning stroke during treatment, symptomatic intracranial hemorrhage during treatment, periodical stroke, and major extracranial hemorrhage during treatment.

Among these issues the most important to patients and their physicians is death or colony at the end of follow-up For this issue the trials of anticoagulants versus antiplatelet agents showed a tendency (that was very nearly statistically significant) in favor of the antiplatelet agent. The trials of anticoagulant plus antiplatelet agent versus antiplatelet agent alone showed no difference between interventions for the primary outcome

All other issues except one showed no difference between interventions or a tendency favoring antiplatelet agents. The solitary outcome that favored anticoagulants was the neighborhood of symptomatic DVT during treatment. This issue is not insignificant, but it pales in comparison with the primary consequence of death or dependency at the fall of the curtain of follow-up. Surprisingly, there was no significant decrease in symptomatic pulmonary embolus in the anticoagulant group

The authors did not find any trials that compared oral anticoagulants with antiplatelet agents. A lately published trial, the Warfarin-Aspirin intermittent Stroke Study, (2) found no difference in rates of death or returning stroke when aspirin was compared with warfarin.

Aspirin is as effective as anticoagulants in reducing death or province and it is at least as safe to use. Because it does not require monitoring, aspirin is easier to use and is to a great degree less expensive than anticoagulants.

To cut down morbidity and mortality from ischemic rap physicians should prescribe 75 to 150 mg of aspirin for day beginning immediately after diagnosis.

REFERENCES

(1) Berge E Sandercock P Anticoagulants versus antiplatelet agents for acute ischaemic thump Cochrane Database Syst Rev, 2003:CD003242

(2) Hankey GJ Warfarin-Aspirin returning Stroke Study (WARSS) trial: is warfarin really a reasonable therapeutic alternative to aspirin for preventing returning noncardioembolic ischemic stroke? Stroke 2002;33:1723-6

(3) Easterbrook PJ Berlin JA, Gopalan R Matthews DR Publication bias in clinical research. Lancet 1991;337:867-72

(4) MacLean CH Morton SC Ofman JJ Roth EA, Shekelle PG; Southern California Evidence-Based Practice Center in what manner useful are unpublished data from the aliment and Drug Administration in meta-analysis? J Clin Epidemiol 2003;56:44-51

RELATED ARTICLE: Cochrane abstract.

Background. Antiplatelet agents effect a small but worthwhile benefit in long-term functional issue and survival, and they have become standard treatment for acute ischemic knock Anticoagulants often are used as an alternative treatment, despite evidence that they are ineffective in producing long-term benefits. The authors1 wanted to review trials that have directly compared anticoagulants and antiplatelet agents to assess whether an anticoagulant regimen tenders net advantages over use of antiplatelet agents, overall or in a particular category of patients (eg patients with atrial fibrillation).