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The article is overly medico-legal in its analysis and though it boasts that it “provides useful learning opportunities”, it misses all the real medical ones. Alleged negligence is clearly a hugely significant concern professionally, but aren’t we concerned medically too? In my strong opinion, this article highlights that guidelines need careful interpretation and presentation to the individual patient, followed by an informed discussion about options from the treating doctor and it is this discussion that needs to be documented .
There are several points for medical consideration to be highlighted from this case, in my opinion.
Anticoagulation should always be continued (unless contraindicated), even after a successful cardioversion where there are other risk factors for stroke and consideration should be given to continuing it in all cases (unless contraindicated), as risk of recurrence of atrial fibrillation (A-fib) is high, especially in older people, and may be high in any given individual (this exact risk may not be known or estimated in the individual without careful trans-oesophageal echocardiogram and/or EP studies).
An ECG or a pulse check is a poor way to either ensure someone is maintained in A-fib or to screen for atrial fibrillation, as it has a poor negative predictive value due to the condition being frequently paroxysmal (it would be analogous to suggest we screen for presence of breast cancer without mammography).
Stroke risk scores such as CHADS2 or even CHA2DS2-VASc in A-fib are a surrogate estimation and again are associated with relatively poor c-statistics for positive prediction of stroke. Neither score can tell you what is really going on with a person’s ‘cement mixer or their cement’ in the analogy of the ‘faulty cement mixer’ for A-fib. The risk of stroke with a CHADS2 score of 0 is 1.9 per cent per annum, for example.
However, risk scores for stroke such as CHA2DS2-VASc in A-fib and the HAS-BLED risk score for bleeding on warfarin are useful as a guide to discussing approximate risks with patients in helping them make a decision whether to opt for anticoagulation or not. This is the most important medical discussion to document.
Risk of stroke is not the same as risk of GI bleeding in terms of mortality or morbidity and this needs to be borne in mind when discussing risk/benefit of anticoagulation with A-fib patients.
Warfarin may well have been one of the ‘barriers’ here to considering longer-term anticoagulation. It is cumbersome to use and take and realistically, it has failed historically as a strategy for stroke prevention in the population. In my opinion, it is no longer first-line treatment for stroke prevention in A-fib and international guidelines are now reflecting this.
It is disingenuous to continue to advocate for widespread use of a drug that we all know would not pass the first stage of modern drug testing, has safety issues compared to modern direct oral anticoagulants in terms of intracranial bleeding and whose body of evidence was originally based on study numbers in the hundreds rather than many thousands with the newer agents.
A-fib is a serious issue, a massive public health concern, the leading cause of severe stroke now and increasingly, a cause of dementia and human misery. Let’s all advocate for a proper technological solution to screening for this condition in our population, particularly in the over-60s.
A-fib fulfils the exact same Wilson-Jungner criteria that makes us screen for breast cancer, so let’s find it, treat it, and make major stroke a thing of the past.
Dr Ronan Collins*,
Director of Stroke Services, Tallaght Hospital, Dublin,
Consultant Physician in Geriatric and Stroke Medicine.
*I have spoken at meetings and reviewed data on advisory boards sponsored by all the manufacturers of the direct oral anticoagulants. I am a member of the Council on Stroke of the Irish Heart Foundation. The views presented are always my own.