Database guide last
updated May 21, 2024

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Wolters Kluwer Health

ACP Journal Club (ACP) is part of Ovid's Evidence Based Medicine Reviews collection, and consists of two journals, ACP Journal Club, a publication of the American College of Physicians, and Evidence-Based Medicine, a joint publication of the American College of Physicians and the British Medical Journal Group.

ACP Journal Club includes studies which ACP's editors have selected as methodologically sound and clinically relevant. The editors screen the top clinical journals for articles, and write enhanced abstracts and commentary on the study's value, helping clinicians to quickly understand and apply to their practice important changes in medical knowledge, without having to read and synthesize thousands of journal articles.

ACP includes bi-directional links with Ovid MEDLINE and Ovid Full text.

ACP Journal Club contains the complete contents of the database dating back to 1991. In January of 2000, ACP Journal Club and Evidence-Based Medicine merged and, as of that date, all new content is listed as coming from the ACP Journal Club. The Evidence-Based Medicine Table of Contents is maintained for issues prior to 2000.

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Accession Number
  00021607-200707000-00022
Title
  Review: Anticoagulants increase intracerebral bleeding and do not 
  reduce death or disability in acute cardioembolic stroke.
Source
  ACP Journal Club. v147(1):p.17, July/August, 2007.
Reviewed Source
  Paciaroni M, Agnelli G, Micheli S, Caso V. Efficacy and safety of
  anticoagulant treatment in acute cardioembolic stroke: a meta-analysis
  of randomized controlled trials. Stroke. 2007;38:423-30.
Commentary Author
  S. Claiborne Johnston, MD, PhD
Commentary Author's Institution
  University of California, San Francisco; San Francisco, California, USA
Keywords
  Anticoagulants;
  Cerebrovascular accident
Abstract
  Question:
  In patients with acute cardioembolic stroke, are anticoagulants effective
  and safe as initial treatment?
  Methods:
  Data sources
  MEDLINE and EMBASE/Excerpta Medica (1980 to February 2006), the Cochrane
  Library (2006, issue 1), bibliographies of relevant studies, and abstracts
  of major international meetings.
  Study selection and assessment
  Randomized controlled trials (RCTs) that compared anticoagulants
  (unfractionated heparin, low-molecular-weight heparin, or heparinoids)
  with other treatments or placebo in patients (randomized within 48 h of
  stroke onset) who received an objective diagnosis of stroke of presumed
  cardioembolic origin and were assessed using objective methods. 7 RCTs
  (n = 4624) were included. 3797 patients had atrial fibrillation, and 827
  had other mixed cardioembolic sources. The anticoagulants were intravenous
  dalteparin (1 RCT), intravenous heparin (2 RCTs), subcutaneous heparin (1
  RCT), intravenous danaparoid (1 RCT), subcutaneous nadroparin (1 RCT), and
  tinzaparin (1 RCT). Studies were assessed for allocation methods, allocation
  concealment, blinding, and completeness of follow-up.
  Outcomes
  A composite outcome of death or disability at >= 3 months, all strokes or
  early recurrent stroke within 14 d, and symptomatic intracranial bleeding.
  Main results:
  Anticoagulants did not differ significantly from placebo or aspirin for
  death or disability, all strokes, or recurrent stroke, but they increased
  the risk for symptomatic intracranial bleeding .
  Conclusions:
  In patients with acute cardioembolic stroke, anticoagulants do not differ
  significantly from placebo or aspirin for the composite outcome of death or
  disability or for stroke, including recurrent early stroke. However, they 
  increase the risk for intracranial bleeding.
Commentary
  Ischemic stroke was commonly treated with short-term anticoagulation 10
  years ago, most frequently with heparin. A series of randomized trials,
  many included in this meta-analysis by Paciaroni and colleagues, showed
  that there was no benefit to anticoagulation when given within hours of
  an ischemic stroke and that it increased the risk for major hemorrhagic 
  complications. However, cardioembolic strokes were not well-represented
  in most of these trials.
  The benefit of long-term anticoagulation with warfarin in patients with
  cardioembolic stroke is well-established. Some experts have argued that
  short-term anticoagulation in patients with recent cardioembolic stroke
  should reduce the risk for early recurrence and that this benefit is
  likely to outweigh the risk for hemorrhagic complications. This meta-analysis
  argues that they are wrong, and in doing so, it eliminates one of the last
  widely accepted indications for full-dose heparin after ischemic stroke.
  This meta-analysis extracted data from subgroups in larger trials (including
  data not previously reported) and thus adds to the literature rather than 
  just summarizing it. With the data clearly presented, the conclusions are
  obvious: Any benefit from short-term anticoagulation in reducing risk for
  recurrent ischemic stroke is outweighed by the risk for hemorrhagic stroke,
  with no net benefit in mortality and disability.
  Prophylaxis of deep venous thrombosis remains an uncertain indication for
  heparins in nonambulatory patients with stroke and is currently being
  studied in randomized trials. The lower doses required for prophylaxis are
  more effective than compression devices, but this benefit may be balanced by
  a greater risk for brain hemorrhage . Patients with cardioembolic transient
  ischemic attack may also benefit from short-term anticoagulation since the
  risk for recurrence is particularly high in these patients, and the risk for
  brain hemorrhage should be substantially lower in the absence of major brain
  infarction. However, this indication needs to be evaluated in trials.
  Short-term aspirin does improve outcomes after ischemic stroke and should be
  given to all patients.
References
  1. Dennis MS. Effective prophylaxis for deep vein thrombosis after stroke:
  low-dose anticoagulation rather than stockings alone: against. Stroke.
  2004;35:2912-3.
  2. Johnston SC. Clinical practice. Transient ischemic attack.
  N Engl J Med. 2002;347:1687-92.
Publication Type
  Therapeutics.
Document Type
  Therapeutics. 

Accession Number
  00021607-200701000-00001
Author
  Straus, Sharon MD, MSc; Haynes, Brian MD, PhD; Glasziou, Paul MBBS, PhD;
  Dickersin, Kay PhD; Guyatt, Gordon MD, MSc
Institution
  University of Calgary; Calgary, Alberta, Canada (Straus)
  McMaster University; Hamilton, Ontario, Canada (Haynes)
  University of Oxford; Oxford, England, UK (Glasziou)
  Johns Hopkins University; Baltimore, Maryland, USA (Dickersin)
  McMaster University; Hamilton, Ontario, Canada (Guyatt)
Title
  Misunderstandings, misperceptions, and mistakes.
Source
  ACP Journal Club. v146(1):p.A8A9, January/February, 2007.
Commentary Author
  Sharon Straus, MD, MSc, Brian Haynes, MD, PhD, Paul Glasziou, MBBS, PhD,
  Kay Dickersin, PhD, Gordon Guyatt, MD, MSc
Commentary Author's Institution
  University of Calgary; Calgary, Alberta, Canada,
  McMaster University; Hamilton, Ontario, Canada,
  University of Oxford; Oxford, England, UK,
  Johns Hopkins University; Baltimore, Maryland, USA,
  McMaster University; Hamilton, Ontario, Canada
Keywords
  Evidence-based medicine
References
  1. Evidence-based medicine. A new approach to teaching the practice
  of medicine. Evidence-Based Medicine Working Group. JAMA. 1992;268:2420-5.
  2. Straus SE, McAlister FA. Evidence-based medicine: a commentary on
  common criticisms. CMAJ. 2000;163:837-41.
  3. Healy B. Who says what's best? US News World Rep. 2006 Sep 3.
  4. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence
  based medicine: what it is and what it isn't. BMJ. 1996;312:71-2.
  5. Hampton JR. Evidence-based medicine, practice variations and clinical 
  freedom. J Eval Clin Pract. 1997;3:123-31.
  6. Swales JD. Evidence-based medicine and hypertension. J Hypertens. 
  1999;17:1511-6.
  7. Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation 
  of internal-mammary-artery ligation by a double-blind technic. N Engl J 
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  8. Failure of extracranial-intracranial arterial bypass to reduce the risk 
  of ischemic stroke.N Engl J Med. Results of an international randomized 
  trial. The EC/IC Bypass Study Group. 1985;313:1191-200.
  9. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in 
  patients receiving encainide, flecainide, or placebo. The Cardiac 
  Arrhythmia Suppression Trial. N Engl J Med. 1991;324:781-8.
  10. Lachetti C, Guyatt G. Surprising results of randomized controlled trials. 
  In: Guyatt G, Rennie D, eds. Users' guides to the medical literature. A manual 
  for evidence-based clinical practice. Chicago: AMA Press; 2002:247-65.
  11. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen 
  plus progestin in healthy postmenopausal women: principal results From the 
  Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-33.
  12. NIH Consensus Statement. Breast cancer screening for women ages 40-49. NIH 
  Consens Statement. 1997;15:1-35.
  13. Merenstein D. A piece of my mind. Winners and losers. JAMA. 2004;291:15-6.
  14. Ilic D, O'Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane 
  Database Syst Rev. 2006;3:CD004720.
  15. Hurwitz B. How does evidence based guidance influence determinations of 
  medical negligence? BMJ. 2004;329:1024-8.
Publication Type
  EBM Trends.
Document Type
  Editorial.

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