A Tale of Two Atria: AF management update.

One of my jobs at the Uni is to corral medical students into producing “grand rounds” presentations.  Usually I try and pick a topic that they need to know, and one that makes for a good discussion.  Recently 4 of my students – Jaz O’Neill, Sally Roberts, Jeffery Smith and Amy Klemm – got handed AF: management as their brief.

In retrospect this was a big ask!  It is fair to say that the acute and longer term management of AF is shrouded in uncertaintly, conflicting evidence and we have a lot of studies with confidence intervals agonisingly close to 1.00!  The team put up a great effort and produce this slideshow:

A tale of two atria (Click to open pdf version)  Have a read – it is 37 ‘slides’.  The idea was to look at 2 patients with different risk, needs and possible prognoses – to illustrate the idea that one protocol does not fit all when it comes to AF.

I certainly learned quite a bit ‘advising’ them and reading the evidence at hand.  A short summary of learning points for the average GP follows:

  • AF is messy, there are a series of decision points – each with relatively weak evidence to guide clinical decision-making.
  • Probably my biggest take away concept: consider the patient and where they are at in the ‘natural history’ of their own AF (age is a big clue) in order to make a rational call on the longer-term management.
  • The Cardiology party line on things such as a 48 hour cut-off for acute cardioversion is based in more commonsense than actual evidence.
  • The Ottawa Protocol folks are either onto something especially good, or just got lucky with their 600 off patients – would be good to see longer term data from this cohort!
  • The rate vs. rhythm control debate is not even close to being resolved – there is a lot of wriggle room.  Largely this decision comes down to patient preference and this requires good information from you – the doctor at the coal face!
  • Anticoagulation – the new players have not provided a panacea – warfarin is still the standard and the newer agents are making a place for themselves – but remain imperfect.  Watch the ACS risk – might prove a tricky one – ?Vioxx all over again?

Ok, have a read and let me know – how would you manage the two patients presented in the slideshow?  Or better yet, if it were yourself – what would you like to do?

Casey

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