Users' Guides to the Medical Literature

THE MEDICAL LITERATURE Users’ Guides to the Medical Literature XVI. How to Use a Treatment Recommendation Gordon H. Guyatt, MD, MSc Jack Sinclair, MD Deborah J. Cook, MD, MSc Paul Glasziou, MB, BS, PhD for the Evidence-Based Medicine Working Group and the Cochrane Applicability Methods Working Group CLINICAL SCENARIO You are a primary care practitioner considering the possibility of anticoagulant therapy with warfarin in a new patient, a 76-year-old woman with chronic congestive heart failure and atrial

fibrillation. The patient has no hypertension, valvular disease, or other comorbidity. Aspirin is the only antithrombotic agent that the patient has received over the 10 years during which she has been in atrial fibrillation. Her other medications include captopril, furosemide, and metoprolol. The duration of the patient’s atrial fibrillation and her dilated left atrium on echocardiogram dissuade you from prescribing antiarrhythmic therapy. Discussing the issue with the patient, you find she places a high value in avoiding a stroke, a somewhat lower value in avoiding a major hemorrhage, and would accept the inconvenience associated with monitoring anticoagulant therapy. You have little inclination to review the voluminous original literature relating to the benefits of anticoagulant therapy in reducing stroke or its risk of bleeding, but hope to find an evidence-based recommendation to guide your ad- vice to the patient. In your office file relating to this problem you find a report of a primary study, 1 a decision analysis, 2 and a recent practice guideline 3 that you hope will help. INTRODUCTION Each day, clinicians make dozens of patient management decisions. Some are relatively inconsequential, some are...

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