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?