overall, 669 patients (16.7%) developed ischemia with exercise. during a mean follow-up of 4.5 3.4...
TRANSCRIPT
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Cómo evaluar un artículo médico ?
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Results
Overall, 669 patients (16.7%) developed ischemia with exercise. During a mean follow-up of 4.5 3.4 years, 313 patients died, and 183 patients had a MACE before any revascularization procedure. The 5-year mortality and MACE rates were 6.4% and 4.2% in patients without ischemia versus 12.1% and 10.1% in those with ischemia, respectively (p 0.001). In the multivariate analysis, WMSI remained an independent predictor of mortality (hazard ratio [HR]: 2.73, 95% confidence interval [CI]: 1.40 to 5.32, p 0.003) and MACE (HR: 3.59, 95% CI: 1.42 to 9.07, p 0.007). The addition of the EE results to the clinical, resting echocardiographic and exercise hemodynamic data significantly increased the global chi-square of the models for the prediction of mortality (p 0.005) and MACE (p 0.009).
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Lancet 2002; 359: 57-61
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Lancet 2002; 359: 57-61
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Lancet 2002; 359: 57-61
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Exposure Outcome
Exposure and outcome at the same time
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Lancet 2002; 359: 57-61
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Lancet 2002; 359: 57-61
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Lancet 2002; 359: 57-61
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Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. P. M. Rothwell et al
LANCET. 2003
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MEDICINA BASADA EN :
Experiencia Conferencia Emergencia Grandilocuencia Jurisprudencia Prepotencia Evidencia
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MEDICINA BASADA EN EVIDENCIAS
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MEDICINA BASADA EN EVIDENCIAS.
“Uso consciente, explícito y juicioso de la mejor evidencia actual en las decisiones acerca del cuidado individual, integrando la experiencia clínica individual con la evidencia clínica proveniente de la investigación”.
Osheroff JA, Forsythe DE, Buchanan, et al. Physicians’ information needs : analysis of questions posed during clinical teaching. Ann Intern Med 1991. 114 : 576 – 581.
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“La Medicina Basada en Evidencias considera que la intuición, la experiencia clínica no sistemática y el razonamiento fisiopatológico no son suficientes para una adecuada toma de decisiones clínicas y hace énfasis en el examen de la evidencia de la investigación clínica”.
Counsell C. Formulating questions and locating primary studies for inclusion in systematic reviews. Ann intern Med 1997. 127:380-387.
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MEDICINA BASADA EN EVIDENCIAS.
“… proceso de traducir problemas clínicos en preguntas para luego buscar, evaluar y utilizar sistemáticamente los resultados de la investigación en la toma de decisiones clínicas”.
Sackett DL et al. How to ask clinical questions you can answer. In: Sackett DL, Richardson WS, Rosemberg W, Haynes RB. Evidence-Based Medicine : How to practice and teach EBM. New York. Churchill-Livingstone. First edition. 1997:21-36
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MEDICINA BASADA EN EVIDENCIA
Necesidad Información Buscar Evidencias Evaluación Evidencias Aplicación Clínica Retroalimentación
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MEDICINA BASADA EN EVIDENCIA
Plantear situación clínica.
-Causalidad. -Intervenciones. -Diagnóstico. -Pronostico.
Literatura Biomédica.
Evaluar Evidencia.
Sintetizar y Aplicar la Información.
PASOS:
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LIMITACIONES M.B.E.
Requiere tiempo. Recursos. Simplificar Práctica (?). Busca reducir costos (?). Estudios Aleatorios y Meta-análisis.
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Rating clinical evidence
Assessment system of the US Preventive Services Task Force
Quality of evidence
1 Evidence from at least one properly designed randomised controlled trial.2-1 Evidence obtained from well-designed controlled trials without randomisation.2-2 Evidence from well-designed cohort or case-control studies. preferably from more than one centre or research group.2-3 Evidence from multiple time series with or without the intervention. Important results in uncontrolled experiments (such as the introduction of penicillin treatment in the 1940s) could also be considered as this type of evidence.3 Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Strength of recommendations
A) Good evidence to support the intervention.B) Fair evidence to support the intervention.C) Insufficient evidence to recommend for or against the intervention. But recommendation might be made on other grounds.D) Fair evidence against the intervention.E) Good evidence against the intervention.
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PREGUNTA CLINICA
Población Exposición Control Desenlace
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PREGUNTA CLINICA
FUNCIONES: Uso Tiempo Estrategias Comunicación Didáctica Confianza
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EVALUACION DE ESTUDIO
1.1 Validez1.2 Resultados1.3 Desenlaces1.4 Aplicación Resultados1.5 Costo: Beneficio
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EVALUACION ESTUDIO
1.1 Validez- Aleatorio?- Seguimiento?- Ciego?- Grupos Comparables?- Igual Tratamiento?
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EVALUACION ESTUDIO
1.2 RESULTADOSa. Riesgo
- Riesgo Relativo (RR)- Odds Ratio (OR)- Reducción Riesgo Relativo (RRR)- Reducción Absoluta Riesgo (RAR)
b. Número Necesario Tratar (NNT)
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EVALUACION RESULTADOS
R.R. = Re/Rne
RR = 1 : No existe Riesgo
RR > 1 : Exposición Riesgo
RR < 1 : Exposición Riesgo
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EVALUACION RESULTADOS
REDUCCION DE RIEGO RELATIVO (RRR)
RRR = (1-RR) 100%
RRR = 0: No Existe Riesgos
RRR > 0: No Exposición Riesgos
RRR < 0: No Exposición Riesgos
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EVALUACION RESULTADOS
REDUCCION ABSOLUTA RIESGO (RAR)
RAR : Rne - Re
RAR = 0 : No Existe Riesgo
RAR < 0 : Exposición Riesgos
RAR > 0 : Exposición Riesgos
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EVALUACION RESULTADOS
NUMERO NECESARIO TRATAR (NNT)
NNT = 1/RAR = 1 (Rne - Re)
NNT = 1 : Tx Ideal
= : Tx Inútil
> 0 : Tx Beneficioso
< 0 : Tx Nocivo
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EVALUACION RESULTADOS
Odds Ratio (OR)
O.R : Oe/One
O.R = 1 : No Existe Riesgo
O.R > 1 : Exposición Riegos
O.R < 1 : Exposición Riegos
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EVALUACION RESULTADOS
Aplicación Práctica ?
Desenlaces Importantes ?
Beneficios > Riesgos ?
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BeneficioRelevante
BeneficioIrrelevante
Beneficio Relativo de Sobrevida (Indice de Riesgo)
THE LANCET. 2001Vol. 357 : 1349.
MEDICINA BASADA EN EVIDENCIAS
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Beneficioso Nocivo
Beneficio Relativo de Sobrevida (Indice de Riesgo)
THE LANCET. 2001Vol. 357 : 1349.
MEDICINA BASADA EN EVIDENCIAS
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PREVENTION OF CORONARY AND STROKE EVENTS WITH ATORVASTATIN Y HYPERTENSIVE PATIENTS WHO HAVE AVERAGE OR LOWER THAN AVERAGE
CHOLESTEROL CONCENTRATIONS, IN THE ANGLO-SCANDINAVIAN CARDIAC OUTCOMES TRIAL LIPID LOWERING ARM (ASCOTT-LLA). Peter S. Sever et al.
LANCET. Vol 361. Abril 5, 2003
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ACE inhibitors in AMI
Curr Probl Cardiol, January 2003
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MEDICINA BASADA EN EVIDENCIAS
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APLICACIÓN RESULTADOS ESTUDIO
FACTORES: Variabilidad Biológica
Aspectos Socio-Económicos
Aspectos Epidemiológicos
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Costo-Efectividad = CA - CB / EA - EB
C= costo. E= efectividad.
A= Tx nuevo.
B= Tx control.