Department of Cardiology, Larissa University General Hospital, Larissa, Greece.
Department of Medicine/Cardiovascular Medicine, The Ohio State University, Columbus, OH, United States.
Hellenic J Cardiol. 2021 May-Jun;62(3):185-189. doi: 10.1016/j.hjc.2020.10.008. Epub 2020 Nov 11.
In emergency situations, such as during the coronavirus disease 2019 (COVID-19) pandemic, medical community looks for quick answers and guidance. Under these circumstances, experts instead of admitting ignorance, feel obliged to give an answer, often pressurized by political or other authorities, even when such an answer is unavailable. Under these circumstances, publications based on fallacious reasoning are virtually unavoidable. In the present review, we summarize examples underlying fallacious reasoning recommendations regarding treatment with Renin-Angiotensin-Aldosterone inhibitors (RAASi) in the COVID-19 context. Most scientific societies emphasize that RAASi use is safe and that these agents should not be discontinued, based mainly on the results of observational studies (OSs) and occasionally preprints, as relevant randomized controlled trials (RCTs) are currently lacking. However, over the past 4 decades, results from successful RCTs have repeatedly proved that practices based on OSs were wrong. Lack of RCTs results in uncertainty. In this setting, the physician's wisdom and knowledge related to pathophysiologic mechanisms and effect of pharmacologic agents become even more important as they may limit fallacies. Based on these principles, in diseases (e.g., mild, or moderate arterial hypertension, etc.) where equally effective alternative therapies to RAASi are available, these therapies should be applied, whereas in diseases (e.g., heart failure, diabetic kidney disease, etc.), where equally effective alternative therapy compared to RAASi is not available, RAASi should be used. Admittedly this strategy, like all the other recommendations, is not based on solid evidence but is intended to be individualized and follows the Hippocratic "Primum non nocere".
在紧急情况下，例如在 2019 年冠状病毒病（COVID-19）大流行期间，医学界寻求快速的答案和指导。在这种情况下，专家们不是承认自己的无知，而是感到有义务给出答案，这种情况往往是由于政治或其他当局的压力，即使没有答案。在这种情况下，基于错误推理的出版物几乎是不可避免的。在本综述中，我们总结了在 COVID-19 背景下治疗肾素-血管紧张素-醛固酮抑制剂（RAASi）的错误推理建议所依据的例子。大多数科学协会强调 RAASi 的使用是安全的，不应停止使用这些药物，这主要基于观察性研究（OS）的结果，偶尔也基于预印本，因为目前缺乏相关的随机对照试验（RCTs）。然而，在过去的 40 年中，成功的 RCT 结果反复证明，基于 OS 的实践是错误的。缺乏 RCT 结果导致了不确定性。在这种情况下，医生的智慧和知识与病理生理机制和药物作用有关，变得更加重要，因为它们可以限制错误推理。基于这些原则，在同样有效的替代疗法可用的疾病（例如，轻度或中度动脉高血压等）中，应应用这些疗法，而在没有与 RAASi 同等有效的替代疗法的疾病（例如心力衰竭、糖尿病肾病等）中，应使用 RAASi。诚然，这种策略与所有其他建议一样，不是基于确凿的证据，而是旨在个体化，并遵循希波克拉底的“首要原则是不伤害”。
