Abstract
In the present era of “evidence-based medicine” the systematic review (often with meta-analysis) is accorded a prominent role in writing of clinical guidelines and setting of health care policy. Herkner et al. [ [1] Herkner H. Thoennissen J. Nikfardjam M. Koreny M. Laggner A.N. Mullner M. Short versus long bed rest after uncomplicated acute myocardial infarction: a systematic review and meta-analysis. J Clin Epidemiol. 2003; 56: 775-781 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar ] report a pooling of randomized trials of duration of bed rest following acute myocardial infarction, mostly undertaken 30 years ago. Unfortunately, this pooling contains errors. The largest primary trial of 742 patients [ [2] West R.R. Henderson A.H. Randomised multi-centre trial of early mobilisation after uncomplicated myocardial infarction. Br Heart J. 1979; 42: 381-385 Crossref PubMed Scopus (22) Google Scholar ] is entered with only 581 patients, thus affecting point estimate, confidence interval, and weighting. This misreading of the third paragraph of results is the more regrettable, because the authors of this review were in touch with the author of the primary trial via the Cochrane Collaboration Heart Group. The second largest trial (Medical Division Royal Infirmary, Glasgow) [ [3] Medical Division Royal Infirmary, Glasgow. Early mobilisation after uncomplicated myocardial infarction. Lancet. 1973; ii: 346-349 Google Scholar ] is wrongly referenced as Boyle, an observational study [ [4] Boyle D.M. Barber J.M. Walsh M.J. Shivalingappa G. Chaturvedi N.C. Early mobilisation and discharge of patients with acute myocardial infarction. Lancet. 1972; ii: 57-60 Abstract Scopus (25) Google Scholar ]. Inclusion or exclusion of primary trials in overviews can, of course, have more profound effects on any “bottom line” summary [ [5] West R.R. Meta analysis re: “psychosocial interventions augment cardiac rehabilitation programmes.”. Evidence Based Med. 1997; 2: 135-136 Google Scholar ]. We note with interest that the reviewers chose to pool earliest reported mortality. When Archie Cochrane and one of us (R.W.) launched the Welsh trial in 1971, we likewise anticipated any outcome difference to appear early. However, the trial showed diverging mortality over the longer term [ [6] West R.R. Henderson A.H. Long term survival of patients mobilised early after acute myocardial infarction. Br Heart J. 1985; 53: 243-247 Crossref PubMed Scopus (7) Google Scholar ]; an unexpected finding, which we believe has not yet been confirmed or refuted by others. Archie Cochrane extorted us to “randomize until it hurts—the clinicians.” It may be worth noting that there is very little experimental evidence relating to bed rest in the context of modern acute cardiac care, but it is nevertheless important that potentially influential reviews are soundly based [ [7] Chalmers I. Foreword. in: Egger M. Davey Smith G. Altman D.G. Systematic reviews in healthcare: meta-analysis in context. British Med Journal, London2001 Google Scholar ].
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