Lanza Gaetano, Giannandrea David, Lanza Jessica, Ricci Stefano, Gensini Gian Franco
Vascular Surgery Department, IRCCS MultiMedica Hospital, Castellanza, Italy.
Neurology Department-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy.
Ann Transl Med. 2020 Oct;8(19):1274. doi: 10.21037/atm-20-1126.
Evidence based medicine (EBM) is the core of current clinical guidelines and is considered as the gold standard of clinical practice. Despite this, a number of limitations and criticisms are moved to EBM. The major one is that this method privileges randomized controlled trials (RCTs), in which the selection of patients is often based on rigid inclusion criteria. The lack of "pragmatism" of some RCTs sometimes makes it difficult to apply guidelines that derive from them to patients observed in clinical practice, who are often affected by comorbidities and disabilities. The new paradigm to overcome this limitation is personalized medicine (PM), which aims to take into account the particular characteristics displayed by the individual. In order to tailor the best treatment for the patient, PM uses EBM but emphasizes the person's specific information from the assessment of the clinic, lifestyle and risk/benefit scores. This narrative review tries to find the best evidence by analysing subgroups and risk scores of patients from meta-analysis and RCTs in order to try to apply PM and to provide good practice points (GPP) on grey aspects and open questions not fully covered by current guidelines on carotid endarterectomy (CEA) and stenting for stroke prevention.
循证医学（EBM）是当前临床指南的核心，被视为临床实践的金标准。尽管如此，循证医学也受到了一些限制和批评。主要的一点是，这种方法优先考虑随机对照试验（RCT），而在随机对照试验中，患者的选择通常基于严格的纳入标准。一些随机对照试验缺乏“实用性”，有时使得将基于这些试验得出的指南应用于临床实践中观察到的患者变得困难，这些患者往往患有合并症和残疾。克服这一局限性的新范式是个性化医疗（PM），其旨在考虑个体所表现出的特定特征。为了为患者量身定制最佳治疗方案，个性化医疗采用循证医学，但强调从临床评估、生活方式以及风险/获益评分中获取的个人特定信息。这篇叙述性综述试图通过分析荟萃分析和随机对照试验中患者的亚组和风险评分来找到最佳证据，以便尝试应用个性化医疗，并就颈动脉内膜切除术（CEA）和用于预防中风的支架置入术的当前指南未完全涵盖的灰色领域和开放性问题提供良好实践要点（GPP）。
