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Rapid Responses: Rapid Responses published:
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Syncope after repair of Fallot's tetralogy
- David E Ward (6 November 2002)
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Paroxysmal atrial fibrillation and fainting
- Mark L Mallet (9 November 2002)
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Evidence based practice DOES incorporate patients' values
- Kevork Hopayian, Suffolk, IP16 4ES (10 November 2002)
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Narrative medicine doesn't reflect evidence for anticoagulation
- Christopher I. Price (23 November 2002)
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David E Ward, Consultant in Cardiology SW17 0QT
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Sir, I was surprised to note an important omission from the "integrated narrative/evidence based" case report concerning a 56 yr old female who undergone correction of Fallot's tetralogy. The patient's recurrent syncopal episodes were, for reasons unexplained in the report, attributed to paroxysmal AF. The authors, two of them with psychiatric interests, seem completely unaware of the fact that the most important cause of syncope after Fallot's repair is ventricular tachycardia (1). Failure to recognise this complication can lead to premature death. The patient therefore requires full cardiological assessment including ventricular electrical stmulation studies. An implantable cardioverter defibrillator would be an appropriate evidence based therapy. Yours David E Ward
1. Bricker JT. Sudden cardiac death and tetralogy of Fallot. Risks, markers and causes. Circulation 1995; 92: 162-3 Competing interests: None declared |
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Mark L Mallet, Specialist Registrar Norfolk and Norwich University Hospital, Norwich NR4 7UY
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Reis et al[1] nicely illustrate some of the practical issues involved in implementing evidence based care, with regard to anticoagulation for paroxysmal atrial fibrillation. However, their statement that “The patient’s syncope might be considered as equivalent to a transient ischaemic attack” deserves further comment. The patient narrative describes what could be presyncopal symptoms associated with palpitation, in addition to the “faint” or “faints”. In the context of congenital heart disease, even corrected, tachyarrhythmias are potentially more likely to cause haemodynamic compromise, and it is likely that this was the cause of her fainting. Syncope or presyncope are very rarely caused by transient ischaemic attacks, although this label seems all too readily applied to what is quite a distinct clinical picture. “Fainting” in the presence of an abnormal heart must always be taken seriously, as indeed it was in this case, but should not be attributed to additional unproven neurological disease. 1 Reis S, Hermoni D, Livingstone P, Borkan J. Case report of paroxysmal atrial fibrillation and anticoagulation. BMJ 2002 Nov 2;325(7371):1018-20 Competing interests: None declared |
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Kevork Hopayian, General Practitioner Leiston Surgery, Suffolk, IP16 4ES
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The heading "Integrated narrative and evidence based case report'" above the title of the paper by Reis et al (1) summarises the basic assumption of the paper, that there are two different approaches to the care of their patient. The authors went further and suggested that the approaches are in conflict. "Patients' values and contexts and the relationships between patients and doctors play a crucial role; evidence is sometimes the minor player". They personify this conflict in a statement when describing the cardiologist's recommendation that the patient goes onto warfarin: "Deliberations between the patient and the doctor came to a head in March 2000". I find it hard to recognise their picture of evidence based practice (EBP); taking account of patients' values and preferences is an integral part of EBP. In this particular case, there appears to have been a dysfunctional consultation between the cardiologist and the patient; the latter stated that she felt that the cardiologist had not considered her feelings and wishes. So where is the difference between the approaches, where is the conflict? I suggest that the conflict lies entirely in the misconceptions about EBP in the literature, which have been ably described and rebutted(2). I (like many other adherents to EBP) could have sent you case reports where we have listened to our patients' beliefs about strokes and about warfarin, giving them the evidence and helping them to make their decision about a lifelong treatment. Few of us could have provided you with extracts from written stories; this might have meant it would not qualify for publication in the BMJ but it would not negate the fact that we have taken account of patients' values and preferences. Only last month, I had my third consultation with a patient recently discharged after a stroke and found to have raised blood pressure in order to answer his queries on the specialist's recommendation that he take warfarin for his atrial fibrillation. We discussed the risks, the likely impact on his life of taking warfarin (including the consumption of alcohol in social outings), and what it meant to him to change from being a person who occasionally consulted a doctor for minor illness to a patient who will have to attend frequently for blood tests. It is worth remembering that when Sackett et al described what evidence based medicine is and is not, they stated: "Increased expertise (in evidence based medicine) is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care"(3). 1. Reis S, Hermoni D, Livingstone P, Borkan J. Integrated narrative and evidence based case report: Case report of paroxysmal atrial fibrillation and anticoagulation. BMJ 2002;325(7371):1018-1020. 2 Strauss S, McAlister F. Evidence-based medicine: a commentary on common criticisms. CMAJ 2000;163(7):837-41. 3 Sackett D, Rosenberg WC, Muir Gray J, Haynes R, Scott Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-72. Competing interests: None declared |
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Christopher I. Price, Senior lecturer stroke medicine Northumbria Healthcare NHS Trust, NE29 8NH
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The clinical review by Reis et al provides a fascinating insight into narrative based medicine(1). However the agenda of the narrative depends upon the correct interpretation of evidence, and there are two aspects of this patient’s circumstances that require clarification. The authors state that “the patient’s syncope might be considered as equivalent to a transient ischaemic attack.” The most widely accepted definition of TIA does not acknowledge syncope(2), and in the absence of focal neurological features, particularly in a patient who is prone to tachyarrhythmia, it should not be considered as a likely diagnosis. Therefore the basis for this lady receiving anticoagulation is dubious, and her syncope might actually cause concern about increased risks attached to warfarin therapy. In a review of the literature, the authors state that a longitudinal study of adults after repair of tetralogy of fallot provided further evidence for this patient being at high risk(3). In this study 12% of patients developed sustained episodes of atrial tachyarrhythmia, and although this was associated with a reduced event-free survival, the rate of stroke was low (3%) and not significantly different from the arrhythmia free group. This should not be considered as compelling evidence in favour of anticoagulation. The narrative provided by the patient reflects her reluctance for anticoagulation, which is supported by reconsideration of the evidence. 1. Reis S, Hermoni D, Livingstone P, Borkan J. Case report of paroxysmal atrial fibrillation and anticoagulation. BMJ 2002;325:1018-20 2. Hankey GJ, Warlow CP. Transient ischaemic attacks of the brain and eye. WB Saunders, London. 3. Harrison DA, Siu SC, Hussain F, MacLoghlin CJ, Webb GD, Harris L. Sustained atrial arrhythmias in adults after late repair of tetralogy of fallot. Am J Cardiol 2001;87:584-588. Competing interests: None declared |
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