心肌梗死二级预防生活方式和膳食指南/共识的质量评价与内容分析

Quality Evaluation and Content Analysis of Lifestyle and Dietary Guidelines/Consensus on Secondary Prevention of Myocardial Infarction

背景健康的生活方式和膳食作为心肌梗死二级预防的重要组成部分,可有效降低再发心肌梗死的危险,改善心肌梗死患者预后。有必要检索相关高质量证据进行总结,以促进心肌梗死二级预防的临床实践。目的系统检索并筛选当前国内外心肌梗死二级预防生活方式和膳食指南/共识,对纳入指南/共识的质量进行严格评价,提取、分析并综合相关指南推荐意见,为心肌梗死二级预防的生活方式和膳食指导提供最佳干预方案,为促进证据的临床转化提供理论依据。方法计算机系统检索各专业指南网站和中英文数据库,包括国际指南协作网(GIN)、英国国家卫生与临床优化研究所(NICE)、苏格兰校际指南协作网(SIGN)、美国国立指南库(NGC)、澳大利亚临床实践指南数据库(ACPG)、新西兰指南工作组(NZGG)、世界卫生组织(WHO)、PubMed、中国知网(CNKI)、万方数据知识服务平台(WanFang Data)、维普网(VIP),有关心肌梗死的指南、规范及专家共识,或内容涉及心肌梗死预防生活方式或膳食指导的相关指南/共识,并请心血管方面专家进行指南推荐及追溯参考文献补充检索相关指南,检索时间为2013-01-01至2018-12-31,并于2019年6月完成检索。采用临床指南研究与评估系统Ⅱ(AGREEⅡ)对指南/共识进行质量评价,归纳总结指南/共识中生活方式和膳食指导的推荐意见。结果共纳入来自美国、英国、澳大利亚、新西兰、中国的10篇指南/共识,其中A级1篇,B级7篇,C级2篇。汇总49条推荐意见,其中生活方式涵盖戒烟、控制饮酒、体质量管理、睡眠管理、情绪管理、体育锻炼6个方面;膳食推荐涵盖饮食习惯、营养结构、膳食模式及膳食目标等相关内容。结论纳入指南/共识的总体质量较高,但还需进一步规范指南/共识的制定和报告流程;心肌梗死指南/共识中有关生活方式和膳食推荐的内容涉及范围较广,为临床实践提供了证据支持。临床医护人员在进行证据转化时应基于最佳证据,将研究证据充分整合到卫生保健提供中,在综合考虑证据应用的促进及阻碍因素、患者的价值观和偏好等后,选择最佳证据进行临床实践;患者指南的制定者应进一步考虑患者等利益相关者的意见,并更具针对性地细化推荐意见,以最终改善患者结局。

Background As an important part of secondary prevention of myocardial infarction,a healthy lifestyle and diet can effectively reduce the risk of recurrent myocardial infarction,and improve the prognosis of patients with myocardial infarction.It is necessary to summarize the high-quality evidence,so as to promote the clinical practice of secondary prevention of myocardial infarction.Objective To systematically retrieve and screen the evidence-based practice guidelines/consensus on lifestyles and dietary for secondary prevention of myocardial infarction at home and abroad and evaluate rigorously the quality of included guidelines/consensus,and to extract,analyze and summarize relevant recommendations in order to provide a theoretical basis for promoting the clinical transformation of evidence.Methods Guidelines/consensus on myocardial infarction,or guidelines/consensus on lifestyle or dietary guidelines for myocardial infarction prevention,were electronically retrieved in the website of Guidelines International Network(GIN),National Institute for Health and Care Excellence(NICE),Scottish Intercollegiate Guidelines Network(SIGN),National Guideline Clearinghouse(NGC),Australian Clinical Practice Guidelines(ACPG),New Zealand Guidelines Group(NZGG),and World Health Organization(WHO),and databases,such as PubMed,CNKI,WanFang Data,and VIP from January 1 in 2013 to December 31 in 2018,and the search was completed in June of 2019.In addition,relevant guidelines/consensus were recommended by cardiovascular experts,and the references of related guidelines/consensus were also searched to supply the guidelines/consensus.Appraisal of Guidelines for Research & Evaluation Ⅱ Instrument(AGREE Ⅱ) was used to evaluate the quality of guidelines/consensus,and then the recommendations for lifestyles and dietary were summarized.Results A total of 10 guidelines/consensus were included from the United States,the United Kingdom,Australia,New Zealand,and China.For the overall quality,one of them was grade A,seven of them were grade B,and two of them were grade C.Finally,49 items of recommendations were summarized including six parts of lifestyles in smoking cessation,alcohol control,weight management,sleep management,emotional management,and physical exercise,and dietary recommendations covering dietary habits,nutritional structure,dietary patterns and dietary goals.Conclusion The overall quality of the included guidelines/consensus is high,but the formulation and reporting process of the guidelines/consensus still needs to be further standardized.The lifestyle and dietary recommendations in guidelines/consensus for myocardial infarction cover a wide range providing evidence for clinical practice.It is recommended that clinical practice should be based on the best evidence,and clinical staff should fully integrate the research evidence into the provision of health care.After considering the promotion and hindrance of evidence application,and patient values and preferences,then the best evidence for clinical practice could be selected.The makers of guidelines/consensus should further consider the opinions of patients and other stakeholders,and then refine the recommendations in a more targeted way to ultimately improve patient outcomes.