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E-Case #18 May 7-11 Rick Ludwig MD A 68 yo retired dentist with Type II diabetes (recently diagnosed), HTN, elevated cholesterol, obesity, and DJD of the knees presents for Physical Exam before traveling to the Southwest. His medical problems are found to be stable, but his heart rhythm is irregularly irregular, a new finding. On questioning, he is totally unaware of this irregular rhythm. An EKG confirms AF. He is not a drinker or smoker. Upon closer review of his chart, an old EKG done about 9 months ago in anticipation of a knee replacement that did not happen also shows AF. An older one, several years earlier, does not. What are the next steps? Thyroid studies are normal, and his echo is unremarkable. Atrial size is at the upper limits of normal, but no valvular abnormalities. Next? Case is discussed with a cardiologist and he is started on warfarin in anticipation of electrical cardioversion. He goes on his trip, gets his INRs done at a local hospital (not covered by his insurance), and returns two weeks later. He is still not therapeutic. He finally does become therapeutic, is anticoagulated for three weeks, and is cardioverted. He goes into sinus. What then? Warfarin should be continued for at least four weeks after successful cardioversion, the thought being that atrial wall motion is not corrected instantly even though fibrillation is. Well, he does not stay in sinus, but reverts to AF. His cardiologist believes he should simply be left in AF since he has absolutely no side effects from it and his rate is easily controlled. What next? Discussion In the JAMA article, which used a decision aid with pictures depicting percentages, and the BMJ article, which used a decision tree approach, patients chose warfarin less often than was recommended by the guidelines. They were better informed and more satisfied with the outcome of their decision. This is consistent with studies on therapy for BPH and CABG, where patients made more conservative decisions when using decision aids. We tend to talk about prevention as if it is an all or none experience. "If I don't take the warfarin I will get a stroke, if I do I won't". Or "Taking warfarin cuts my risk of stroke in HALF". Knowing that the risk of stroke with ASA is 8 out of 100 may be seen as excellent odds and good enough compared to the hassle of warfarin and the bleeding risk. Decision aids would also be of use when deciding on ordering a PSA, taking alendronate for osteoporosis, and a statin for primary prevention of CAD.
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