Users' Guides to the Medical Literature
Guyatt G, Rennie D, Meade MO, Cook DJ
Part G Moving from Evidence to Action
Chapter 22.4. Grading Recommendations
Holger J. Schünemann, Gunn E. Vist, Roman Jaeschke, Regina Kunz, Deborah J. Cook, Gordon Guyatt
atrial fibrillation, congestive heart failure, grading recommendations, hypertension, stroke prevention, warfarin
"You are the primary care physician considering the possibility of
warfarin use for a 76-year-old woman with congestive heart failure
and chronic atrial fibrillation (AF) who had just entered your practice.
The patient has received aspirin for the 10 years she has had AF.
Her other medical problem is hypertension, for which she has been
taking hydrochlorothiazide and metoprolol, which also control her
heart rate. She does not have valvular disease, diabetes, or other comorbidities,
and she does not smoke. Your assessment of the clinical
practice guideline (see Chapter 21, How
to Use a Patient Management Recommendation) and the decision
analysis, together with the exploration of the patient's
values, indicated that she would be best served by taking warfarin
to prevent strokes (strong recommendation, based on high-quality evidence).
You reflect that an increasing number of clinical practice guidelines are
valid and that you are using them more and more. You decide to learn
about the grading system used in the guideline.
You send an e-mail to the author of the chapter describing the methods
that the guideline authors used; he sends you 2 articles to help
you understand how evidence is graded and recommendations are made
in practice guidelines.1,2..."
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