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PRACTICE: Tony Kendrick, Kelsey Hegarty, and Paul Glasziou Interpreting research findings to guide treatment in practice BMJ 2008; 337: a1499 [Full text]

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PICO and atrial fibrillation

Peter J Bourdillon   (12 January 2009)

PICO and atrial fibrillation 12 January 2009
Peter J Bourdillon, Hon. Senior Lecturer ECG Dept, Hammersmith Hospital, London, W12 0HS Send response to journal: Re: PICO and atrial fibrillation	A seminal example of how to interpret research findings to guide treatment in practice1 is surely the paper by Thomson et al.2 On reading it in 2000 I modified my management of patients with atrial fibrillation. Atrial fibrillation is treated because of symptoms, including breathlessness, and because of the risk of stroke. Like cognitive behavioural therapy for depression, both cardioversion and ablation therapy for atrial fibrillation are rarely available at short notice, so the treatment options are pharmacological rate (and rhythm) control with or without anticoagulation. Thomson’s paper is about the benefits and risks of anticoagulation. The components of Box 2 of Kendrick’s paper1 can be found in Thomson’s paper: Population - the absolute risk of recurrent stroke was derived from the Oxfordshire Community Project and a community study was used to determine bleeding rates on anticoagulants; Intervention - a meta-analysis of the effectiveness of anticoagulation and antiplatelet therapies in patients with atrial fibrillation was undertaken; Context or comparator treatments - aspirin and warfarin were considered as potential therapies for reducing the risk of stroke and co-morbidity was also addressed; Outcome - interviewed patients were asked to rate the health states (no adverse effect, a major bleed, a mild stroke and a severe stroke) associated with the use of anticoagulants. The combination of the flowchart in Thomson’s figure 1 and the look- up tables in figures 2 and 3 – similar to the Cardiovascular Risk Prediction charts at the back of the British National Formulary - can guide the doctor and the patient as to whether or not the benefits of anticoagulation outweigh the risks. By the time a patient is seen in secondary care, most know that anticoagulation is a treatment option and consequently find it easy to follow the flowchart and the look-up tables in the clinic. Understanding the balance of benefits and risks, the patient is then in a position to decide whether or not to take anticoagulants long-term. If given a copy of the flowchart and a copy of the relevant age- and gender-matched look-up table to take home, the patient can discuss the decision with another health professional, with family or with friends in case of lingering doubt. The National Clinical Guideline for the management of atrial fibrillation in primary and secondary care3 does mention the Thomson paper, but it is only in the context of cost-effectiveness. I submit the paper’s importance needs reassessment. 1. Kendrick T, Hegarty K and Glasziou P. Interpreting research findings to guide treatment in practice. BMJ 2008;337:a1499 2. Thomson R, Parkin D, Eccles M et al. Decision analysis and guidelines for anticoagulant therapy to prevent stroke in patients with atrial fibrillation (erratum appears in Lancet 2000 Apr 22;355(9213):1466). Lancet. 2000;355(9208):956–962 3. National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians, 2006 Competing interests: None declared