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E VIDENCE - B ASED M EDICINE

深海魚油可以降低心血管疾病發生率和死亡率 ?. E VIDENCE - B ASED M EDICINE. Supervisor: 王啟忠 主任 Presentation: Intern 吳佩珊. 2013, May 14 th. Outline. Clinical Scenario – 臨床場景 Asking – 提出問題 Acquire – 搜尋資料 Appraisal – 嚴格評讀 Apply – 臨床應用 Audit – 自我評估. Clinical Scenario- 臨床場景.

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E VIDENCE - B ASED M EDICINE

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  1. 深海魚油可以降低心血管疾病發生率和死亡率?深海魚油可以降低心血管疾病發生率和死亡率? EVIDENCE - BASED MEDICINE Supervisor:王啟忠 主任 Presentation: Intern 吳佩珊 2013, May 14th

  2. Outline • Clinical Scenario – 臨床場景 • Asking – 提出問題 • Acquire – 搜尋資料 • Appraisal – 嚴格評讀 • Apply – 臨床應用 • Audit – 自我評估

  3. Clinical Scenario-臨床場景 • 王先生今年 62 歲，高血壓已服藥 (CCB) 將近 10 年，血壓控制良好。體重過重 (BMI:26)，是個老菸槍，常常咳嗽有濃痰。 • 王先生年過60歲，開始擔心身體狀況，他想知道每天吃深海魚油，可否降低未來發生心血管疾病的機率？

  4. Asking-提出問題 • Question: • 服用深海魚油是否可以降低心血管疾病發生率和死亡率?

  5. Asking - 提出問題

  6. Acquire- 搜尋資料 • 關鍵字 :fish oil supplement, cardiovascular risk • 資料庫 : PubMed • 優先順序 : 1 2

  7. Acquire-key word

  8. 符合搜尋條件的文獻 CVD=cardiovascular disease

  9. Appraisal-嚴格評讀 • 一篇好的系統性回顧研究應該符合 • 1.要研究的題目是否有明確定義好? • 2.搜尋策略是否完整、無遺漏? • 3.列入條件和排出條件是否有事先定義? • 4.收錄的研究品質是否良好? • 5.各研究的結果相似?

  10. Yes! • 要研究的題目是否有明確定義好?

  11. Yes! • 搜尋策略是否完整、無遺漏? We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (up to August 2012) . . . Data extraction was performed independently by 2 investigators and discrepancies were resolved by another.

  12. Yes! • 列入條件和排出條件是否有事先定義? We considered all randomized trialsevaluating omega-3 PUFA supplementation in adult participants. Eligible outcomes included all-cause mortality, cardiac death, sudden death, MI, and alltypes of stroke. We excluded studies with treatment duration less than 1 year, allowing for enough time for the treatment to prove efficacy on CVD prevention.

  13. Yes! • 收錄的研究品質是否良好? We assessed the methodological quality of the included trials and the risk of bias conferred by using elements of the Cochrane collaboration tool for assessing risk of bias. Most studies were of high methodological quality

  14. 各研究的結果相似? The presence of statistically significant heterogeneity was assessed by theCochran Q statistic (significant heterogeneity at P<0.10) and the extent of the observed heterogeneity was assessed by the I square I-square大於50%表示文獻異質性太高

  15. Yes!

  16. Appraisal - 評讀結果 Yes! • 要研究的題目是否有明確定義好? • 搜尋策略是否完整、無遺漏? • 列入條件和排出條件是否有事先定義? • 收錄的研究品質是否良好? • 各研究的結果相似? Yes! Yes! Yes! Yes!

  17. Results

  18. P:mixed prevention group • I:omega-3 PUFA supplements • O: reduction of all-cause mortality

  19. P:2nd prevention group • I:omega-3 PUFA supplements • O: reduction of all-cause mortality

  20. Overall, omega-3 PUFA supplements to reduce all-cause mortality

  21. 分群分析 • Prevention setting • Blinding • Dosage

  22. 服用深海魚油(omega-3 PUFAs )對於改善心血管疾病的發生率、死亡率並沒有達到沒有統計學上的顯著差異。

  23. However….

  24. 並無 primary prevention 的RCT • 只蒐集到4篇 mixed primary/secondary prevention 的RCT

  25. 再度搜尋 • Review 4 篇mix primary /secondary 的RCT • 於pubmed搜尋含primary prevention 的RCT….. • 關鍵字: fish oil supplement,cardiovascular ,“Primary prevention”

  26. 搜尋結果: • 4篇包含primary prevention RCT • Primary and secondary prevention populations reported separately onlyin1RCT

  27. Study 設計與臨床場景不符合

  28. Apply –回到病人身上

  29. The bottom line is… • 服用深海魚油是否可以降低心血管疾病發生率和死亡率? • 目前最佳證據顯示: • 服用深海魚油對於整體族群或已有心血管疾病者，無法改善心血管疾病發生率或死亡率 • 對於健康或低風險族群目前沒有證據等級足夠的文獻證明深海魚油對心血管疾病的影響

  30. Audit-自我評估 • 提出臨床問題 • 提出的問題是否具有臨床重要性？ • 是否明確陳述問題？

  31. 搜尋最佳證據 • 已盡全力搜尋？ • 最佳證據來源? • 從大量的資料庫來搜尋答案？ • 使用同義詞、MeSH term、限制（limiters)等方法來搜尋?

  32. 嚴格評讀文獻 • 是否盡全力做評讀了？ • 評讀後是否做出了結論？

  33. 臨床應用 • 是否將搜尋到的最佳證據應用到在病人身上？

  34. Thank you !!!

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