Richard Bogle is a Consultant Cardiologist based in London and Surrey. He specialises in the assessment and treatment of patients with all types of heart and vascular disease. He tweets at @richardbogle
If you watched the news this week you might have thought that the only recommendation in the NICE Atrial Fibrillation Guideline was that doctors should not prescribe aspirin to prevent strokes. In fact most cardiologists and geriatricians stopped using aspirin for this condition several years ago and the NICE recommendation simply reaffirms those issued previously by other professional societies such as the European Society of Cardiology.
The real story behind the guidelines was, in my opinion, nothing to do with medication or rate versus rhythm but rather the importance of delivering a personalised package of care for patients with atrial fibrillation (AF). Recognising that AF is a long term health condition there is emphasis on the importance of shared decision making processes particularly around anticoagulation. Alongside the guideline NICE published a Patient Decision Aid to assist with this process. The intention behind this is good but having shown the 36 page decision aid document to several patients today they were overwhelmed by the volume of information they were expected to digest. The aid includes much information that would not be relevant to the individual patient since it tries to cover the risks and benefit of all patients with various stroke and bleeding risks. It uses Cates plots to try and aid the decision making process but each chart has 1000 faces and only looks at the risks/benefits over one year so the faces benefiting from treatment are swamped by hundreds of faces not expecting any benefit. On a practical note NICE assumes that clinicians will have ready access to a colour printer otherwise the red/greens charts look somewhat monotone. The comparison of this decision aid with the highly professional and dynamic way information is presented on the JBS3 risk calculator website is striking and NICE need to up their game to make this and further decision aids much more user friendly. Summarising the information on two sides of A4 is aspirational but possible as has been done with other documents on breast and prostate cancer screening as has been promoted by the work of Gerd Gigerenzer.
The guideline emphasises that the patient’s decision regarding anticoagulation will be affected by their own attitude towards risk and NICE say that if patients are provided with the appropriate information about the pros and cons they should be able to decide for themselves about whether to have treatment with anticoagulation or not. This removes the recommendation or opinion of the healthcare provider from the consultation and devolves the decision making to the patient. This represents a change in the doctor patient relationship and the dynamics of the consultation. In my experience, patients want to know the pros and cons of a particular treatment but are also interested in the opinion of the healthcare professional especially if they are well known and trusted. In everyday life we use rules of thumb – so called heuristics and recommendations from friends and family feed into the ability to make complex decisions. Often personal experience and anecdotes are trusted in preference to scientific evidence. To devolve the decision making completely to the patient might be seen as convenient for the healthcare professional. If the patient chooses anticoagulation and then bleeds – it was the patient’s decision to start the treatment, not the doctors. If the patient decides not to take anticoagulation and has a stroke then again it was their decision.
In practice clinical medicine is complex and the interaction between a patient and an experienced clinician vital to make a detailed and appropriate assessment. Although stroke and bleeding risk can be calculated using scoring systems these measures are not perfect and derive from large populations which do not necessarily apply to the patient in the consulting room who may have complex multisystem disease and polypharmacy. The risk assessment tools are a starting point of the conversation about treatments. NICE should be commended for placing the patient’s involvement in deciding their management of AF centre stage. This is a clear move in the right direction for patients and should improve both outcomes of this common condition.