… that may go WRONG !! Search priority Key words –Broaden? Narrow? Expressions
Key Words Shift the WORDs –Aspirin <> Antiplatelet –Coumadin <> Anticoagulation –Stroke <> CVA DO NOT Use shortcuts
Guideline National Clearing House www.GUIDELINE.gov www.NGC.org Always search for published guidelines A guideline is any document that aims to streamline particular processes according to a set routine
Conclusions Long-term anticoagulation may be more effective than antiplatelet treatment for preventing nonfatal stroke but not other vascular events in patients with nonrheumatic AF. In patients with acute ischemic stroke, anticoagulants used alone or with antiplatelet agents are not superior to antiplatelet agents used alone. There is no evidence that stroke patients with a normal heart rhythm benefit from anticoagulants.
Abstracts: Cochrane Review In most ischaemic strokes, the blockage is caused by a blood clot. Anticoagulant drugs, such as warfarin, may prevent such clots forming and hence could prevent stroke. However, anticoagulant drugs may also cause bleeding in the brain and this complication could offset any benefits. This review identified a number of trials, in patients who had had a stroke, of anticoagulants to prevent further strokes. There was good evidence that anticoagulants could cause serious bleeding, and there was no evidence that anticoagulants were of benefit. However, other trials show that patients with an irregular heartbeat (atrial fibrillation) and a recent stroke due to a blocked artery do benefit from anticoagulants. New trials are underway to see whether stroke patients with a normal heart rhythm can get greater benefit from anticoagulants than from standard clot-preventing treatments such as aspirin and other antiplatelet drugs. P Sandercock, O Mielke, M Liu, C Counsell; Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack. 2003
Clinical Applications Prevention of Noncardioembolic Cerebral Ischemic Events: Oral Anticoagulants –For most patients with noncardioembolic stroke or TIA, the guideline developers recommend antiplatelet agents over oral anticoagulation (Grade 1A). –For patients with well-documented prothrombotic disorders, the guideline developers suggest oral anticoagulation over antiplatelet agents (Grade 2C).
Clinical Applications Patients with Stroke with Underlying Atrial Fibrillation: Antiplatelet Agents –For patients with cardioembolic stroke who have contraindications to anticoagulant therapy, the guideline developers recommend aspirin (Grade 1A).
Clinical Applications Patients with Aortic Atheromata –In patients with stroke associated with aortic atherosclerotic lesions, the guideline developers recommend antiplatelet therapy over no therapy (Grade 1C+). For patients with cryptogenic stroke associated with mobile aortic arch thrombi, the guideline developers suggest either oral anticoagulation or antiplatelet agents (Grade 2C).
Clinical Applications Patients with Patent Foramen Ovale (PFO) –In patients with cryptogenic ischemic stroke and a patent foramen ovale, the guideline developers recommend antiplatelet therapy over no therapy (Grade 1C+), and suggest antiplatelet agents over anticoagulation (Grade 2A).
Clinical Applications Mitral Valve Strands and Prolapse –In patients with mitral valve strands or prolapse, who have a history of TIA or stroke, the guideline developers recommend antiplatelet therapy (Grade 1C+).
Key Point Guideline or System Reviews are favoured –Clinical Application –Conclusion Critically appraisal for the result of Pubmed Search –Guideline and SRs are NOT AVAILABLE