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Evidence Based Case Report Peripheral Arterial Disease

Kelompok I-B Rena Winanti Stella Margaretha Youdiil Ophinni Karina Faisha Seprializa

Clinical Question
Pada pasien usia tua dengan klaudikasio intermiten, seberapa akuratkah pemeriksaan ankle-brachial index untuk mendiagnosis penyakit arteri perifer apabila dibandingkan dengan MR angiografi?

Clinical Question: PICO


P I C O

..seberapa ..dibandingka Pada ..untuk pasien usia akuratkah n dengan MR mendiagnos tua dengan pemeriksaa angiografi is PAD? n ABI klaudikasio intermiten

Search Strategy
Database
Pubmed

Search strategy
"ankle brachial index" and "magnetic resonance" and (peripheral arterial disease OR peripheral arterial occlusive disease) AND elderly

Hits
23

Selected articles
1

Cochrane

Ankle brachial index AND Magnetic Resonance AND Peripheral arterial disease
ankle brachial index AND peripheral AND arterial AND (occlusive OR disease) AND magnetic resonance angiography AND elderly AND specificity AND sensitivity OR predictive

Medline

383

Ankle Brachial Index PubMed Exclusion criteria: -Journal published before 2005 -Animals -Language other than English/Indonesian

A N D

Magnetic Resonance Angiograph y Cochrane

A N D

Elderly

Medline Inclusion criteria: - Published in the last 5 years -Humans -English/Indonesian

23

383

12

116

Filtering doubles 93 Exclusion criteria: -Irrelevant to our clinical question -Study other than diagnostic study - Age < 45 years Screening title abstract*

Inclusion criteria: -Relevant to our clinical question -Diagnostic study - Age > 45 years

Full text available

Useful: 1 article

Search date: 2 June 2010 *All decisions were made by consensus or at least 2 authors

CRITICAL APPRAISAL

Validity of study
Was there an independent, blind comparison with reference (gold) standard diagnosis? Was the diagnostic test evaluated in appropriate spectrum of patients (like those in whom it would be used in practise) Was the reference standard applied regardless of the diagnostic test result? YES??blinding?

Yes, Elderly w/ clinical character prevalence of atherosclerosis change

Yes

Importance
The results of the study (ABI and MRA examinations) were differentiated between findings in right leg (n = 268) and left leg (n = 265). Findings for ABI as the diagnostic test were regarded as positive if ABI < 0,9 and negative if ABI 0,9. Findings for MRA as the gold standard were positive if arterial stenosis 50% and negative if stenosis < 50%.

RIGHT LEG
Ankle-Brachial Index Total < 0,9 0,9

Magnetic Resonance Angiography

Total 12 256 268

Stenosis 50%
10 41 51

Stenosis < 50%


2 215 217

Sn = 10/51 = 20 % Sp = 215/217 = 99% PPV = 10/12 = 83% NPV = 215/256 = 84% LR+ = 20%/1% = 20 LR- = 80%/99 %= 0.8

Pre-test probability = 51/268 = 19% Pre-test odds = 19%/82% = 0,24 Post-test odds = 0.24 x 20 = 4.7 Post-test probability = 4.7/5.7 = 0.82

LEFT LEG
Ankle-Brachial Index Total < 0,9 0,9

Magnetic Resonance Angiography

Total 11 254 265

Stenosis 50%
9 52 61

Stenosis < 50%


2 202 204

Sn = 9/61 = 15 % Sp = 202/204 = 99% PPV = 9/11 = 82% NPV = 202/254 = 80% LR+ = 15%/1% = 15 LR- = 85%/99% = 0.86

Pre-test probability = 61/265 = 23% Pre-test odds = 23%/77% = 0,3 Post-test odds = 0.3 x 15 = 4.5 Post-test probability = 4.5/5.5 = 0.82

RIGHT LEG
Ankle-Brachial Index Total < 0,9 0,9

Magnetic Resonance Angiography

Total 12 256 268 Total 11 254

Stenosis 50%
10 41 51

Stenosis < 50%


2 215 217

LEFT LEG
Ankle-Brachial Index < 0,9 0,9

Magnetic Resonance Angiography Stenosis 50% 9 52 Stenosis < 50% 2 202

Total

61

204

265

Apply this validity


Is the diagnostic test YES available, affordable, accurate, and precise in your setting? Can you generate a clinically Yes sensible estimate of your patients pre-test probabilitiy?

Will the resulting post-test probabilities affect your management and help your patient? Would the consequences of the test help your patient?

Yes

Yes

NOTES
Blinding? LR+ 20 & 15 kenapa? ABI memiliki spesivisitas dan tinggi dan sensitivitas yang rendah, apakah lebih baik dari MR angiografi?