Análise crítica de artigo de Revisão Sistemática e Metaanálise de ECR

Apresentação em tema: "Análise crítica de artigo de Revisão Sistemática e Metaanálise de ECR"— Transcrição da apresentação:

1 Análise crítica de artigo de Revisão Sistemática e Metaanálise de ECR
Effect of antihypertensive treatment at diferent blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses (Mattias Brunström, Bo Carlberg ) 2017

2 Systematic review and meta-analyses of randomised controlled trials in accordance with the recommendations from the Cochrane collaborations and the PRISMA statement. Aim - To assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in people with diabetes mellitus, at different blood pressure levels.

3 Revisão Sistemática e Metaanálise
Etapas A) Formular a pergunta: Hipótese testada? Exposição e desfechos definidos?

4 Hipótese. Exposição. Antihypertensive treatment Desfechos
Hipótese? Exposição? Antihypertensive treatment Desfechos? Mortality and cardiovascular morbidity in people with diabetes mellitus, at different blood pressure levels. Primary end points will be all cause mortality, myocardial infarction, stroke, congestive heart failure, end-stage renal disease, amputation and blindness. As secondary end points, cardiovascular and non-cardiovascular mortality will be used.

5 Etapas B) Definir critérios de inclusão e de exclusão de estudos
Revisão Sistemática e Metaanálise B) Definir critérios de inclusão e de exclusão de estudos (de acordo com a questão clínica da hipótese da revisão) Desenho: ensaios clínicos, estudos observacionais Participantes: sexo, idade, características clínicas  Exposição: dose, duração Desfecho: morte, cura, melhora, prevenção

6 We included randomised controlled trials with a mean follow-up of 12 months or more and including 100 or more participants with diabetes mellitus. Trials had to compare any antihypertensive agent against placebo, any two agents against one, or any blood pressure target against another. There will be no restrictions regarding co- morbidity or overall cardiovascular risk. Both hypertensive and normotensive patients will be accepted. Trials comparing any blood pressure level with placebo. Trials comparing any two, or more, blood pressure levels. Trials evaluating specific drug doses, independent of pressure goals. Trials with combined interventions will be excluded.

7 Etapas C) Identificação de estudos
Revisão Sistemática e Metaanálise C) Identificação de estudos Bases eletrônicas (através de palavras-chave): Medline - medicina e saúde Lilacs - saúde (América Latina e Caribe) Embase, Scisearch – entre outros. Cochrane - medicina baseada em evidência Outras fontes Especialistas, congressos, simpósios Busca manual de artigos (Referências bibliográficas de artigos)

8 Data sources - Central, medline, embase, and biosis were searched using highly sensitive search strategies. When data required according to the protocol were missing but trials were potentially eligible, we contacted researchers, pharmaceutical companies, and authorities. During February 2013, we searched CENTRAL, Medline, Embase, and BIOSIS using broad strategies to maximise sensitivity. CENTRAL was searched using the MeSH terms “antihypertensive agent” and “blood pressure”, exploded and combined, without restrictions in publication year or language (see the web appendix for full search strategies in each database). We also browsed reference lists in, and citations of, systematic reviews and guidelines in the discipline, including a more recently updated review.

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10 Etapas D) seleção de estudos Segundo critérios de inclusão/exclusão
Revisão Sistemática e Metaanálise D) seleção de estudos Segundo critérios de inclusão/exclusão Pela avaliação da qualidade do estudo – diferentes instrumentos - checklists/guidelines Apresentação de fluxograma

11 Eigibility criteria - Randomised controlled trials including 100 or more people with diabetes mellitus, treated for 12 months or more, comparing any antihypertensive agent against placebo, two agents against one, or di erent blood pressure targets. Both authors independently checked the abstracts and full text articles for eligibility and resolved any disagreements by discussion. Risk of bias was assessed at study level using the Cochrane Collaboration’s risk of bias tool. Both authors independently extracted data and assessed risk of bias, with disagreements resolved by a recheck of the original data and discussion.

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13 COCHRANE’S RISK OF BIAS TOOL
This tool take into consideration six domains, 1) sequence generation, 2) allocation concealment, 3) blinding, 4) incomplete outcome data, 5) selective outcome reporting, and 6) other sources of bias, including early stop and baseline imbalance.

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15 Etapas E) Extração da informação – como foi realizada?
Revisão Sistemática e Metaanálise E) Extração da informação – como foi realizada? Formulário para extração de dados Mínimo de 2 investigadores  

16 Data were extracted into specially designed Excel sheets, pretested on 10 included trials and then modified to increase functionality.

17 Etapas Revisão Sistemática e Metaanálise F) Análise Construção de tabelas com todos os artigos avaliados e principais resultados Metaanálise Gráficos Explorar fontes de heterogeneidade (clínica X metodológica) (P-valor < 0,10) & (I2> 50% ) Escolha da medida de associação (RR, OR) ou efeito Cálculo de medida-sumário

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19 We calculated relative risks for each outcome in each trial, and pooled results using random e ects meta-analysis. We chose the random e ects model over the xed e ects model because the included trials di ered to some extent, both clinically and methodologically. Heterogeneity was assessed by visually inspecting the forest plots, and through I2 statistics. When heterogeneity was present, we scrutinised baseline characteristics, blood pressure data, and risk of bias assessments of the included trials for possible explanations.

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21 TRATAMENTO SEM TRATAMENTO

22 TRATAMENTO CONTROLE

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25 Etapas G) Interpretação dos resultados força da evidência
Revisão Sistemática e Metaanálise G) Interpretação dos resultados força da evidência relevância para pacientes: benefícios x riscos

26 Results 49 trials, including participants, were included in the meta-analyses. Most of the participants had type 2 diabetes. If baseline systolic blood pressure was greater than 150 mm hg, antihypertensive treatment reduced the risk of all cause mortality (relative risk 0.89), cardiovascular mortality (0.75), myocardial infarction (0.74), stroke (0.77), and end stage renal disease (0.82). If baseline systolic blood pressure was mm hg, additional treatment reduced the risk of all cause mortality (0.87), myocardial infarction (0.84), and heart failure (0.80). If baseline systolic blood pressure was less than 140 mm hg, however, further treatment increased the risk of cardiovascular mortality (1.15, 1.00 to 1.32), with a tendency towards an increased risk of all cause mortality (1.05, 0.95 to 1.16). Conclusions Antihypertensive treatment reduces the risk of mortality and cardiovascular morbidity in people with diabetes mellitus and a systolic blood pressure more than 140 mm hg. If systolic blood pressure is less than 140 mm hg, however, further treatment is associated with an increased risk of cardiovascular death, with no observed benefit.

27 Avaliar a Validade interna: Presença de possíveis Vieses
Revisão Sistemática e Metaanálise Avaliar a Validade interna: Presença de possíveis Vieses Viés de Publicação (gráfico de funil) 2. Viés de Idioma  3. Viés de informação Viés de extração Viés do investigador

28 Publication bias was assessed using funnel plots for all outcomes separately, and for mortality in the stratified analyses.

29 This systematic review and meta-analyses included a large amount of previously unpublished data, thereby increasing precision compared with previous research.

30 Trabalho final Selecionar uma revisão sistemática com metaanálise de ECR - enviar por até dia 09/01 para o monitor avaliar se atende aos critérios estipulados (professores disponíveis) Dupla, seguir roteiro exposto Dúvidas e andamento do trabalho em 10/01 (presencial) Escolher um gráfico forest plot para interpretar Entregar impresso até 17/01