Shared Decision Making in Atrial Fibrillation

Abstract

You are seeing Mr Roberts, a 69-year-old retired office manager referred from the emergency department for treatment of atrial fibrillation (AF). He presented the previous night to the emergency department with shortness of breath and palpitations and was found to be in AF with a rapid ventricular response and a heart rate of 140 bpm. He was treated with intravenous diltiazem and spontaneously converted to sinus rhythm. He was then discharged from the emergency department with an outpatient cardiology appointment. He has a background history of hypertension but no other cardiac disease. His only medication is a thiazide diuretic. On questioning, he reports experiencing several episodes of palpitations over the last 2 to 3 years; typically, these are brief and self-limited. His transthoracic echocardiogram, thyroid studies, and electrolytes are all within normal limits. His ECG shows sinus rhythm with no other significant abnormality. His CHADS 2 score is 1 and CHA 2 DS 2 -Vasc score is 2. He has a family history of gastrointestinal hemorrhage-associated death and is uncomfortable about long-term anticoagulation. Additionally, he is reluctant about taking a daily medication plus his blood pressure pill. How might you present current best practice while ensuring that his treatment program is consistent with his goals, values, and preferences? Introduction AF is the most common arrhythmia requiring treatment, affecting ≈5 million Americans, with the prevalence expected to double by 2050.1-3 AF accounts for more than a third of all hospitalizations for cardiac rhythm disturbances. Hospitalization for AF has risen dramatically over the past 20 years and is projected to continue to rise as the population ages. 4 Importantly, AF is associated with a doubling in patient-matched and adjusted mortality.5 Atrial fibrillation can range from completely asymptomatic to highly symptomatic and can negatively affect patients' quality of life if left untreated. 6 Studies have demonstrated significant gaps in AF patient's knowledge about their condition, as well as knowledge of the risks and benefits of the treatment they are currently taking for their AF despite their disease being treated for several years. 7A landmark study in 2007 observed multidisciplinary groups of clinicians and patients discussing AF management and noted that all groups recognized the difficulties in managing the disease, but no group agreed with the other on the optimal way to improve patient care.8 A meta-synthesis of qualitative studies from 2012 examined the perspectives of both clinicians and patients and found that patients often experienced a paternalistic model of decision making, whereas clinicians involved in these same conversations reported that a shared decision making (SDM) model was used. 9 This discordance has been reported by other studies and indicates that patients wish for more information about their treatment options and that clinician bias and practice style, not patient preferences, influenced the outcome of starting oral anticoagul...

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Jako czynniki ryzyka nawrotu po ablacji przezcewnikowej AF zidentyfikowano wiele zmiennych, ale ich wartość predykcyjna pozostaje mała. Decyzja o ablacji przezcewnikowej powinna więc być wynikiem procesu wspólnego podejmowania decyzji [747] (patrz rozdz. 8), po dokładnym wyjaśnieniu potencjalnych korzyści i zagrożeń, a także alternatywnych sposobów postę-powania, takich jak stosowanie leków antyarytmicznych lub akceptacja objawów występujących w danym momencie bez podejmowania leczenia w celu kontroli rytmu serca [175].…”

“…Jest również bardzo prawdopodobne, że dla długoterminowego leczenia przewlekłych stanów, takich jak AF, korzystne jest dobre poinformowanie pacjentów, którzy zdają sobie sprawę z własnych obowiązków w ramach procesu leczenia choroby [328]. Dzięki wspólnemu podejmowaniu decyzji [747] i zorganizowaniu opieki w sposób ześrodkowany na pacjencie (patient-centred care) można ułatwić przestrzeganie zaleceń terapeutycznych, wzmocnienie pozycji pacjentów oraz poszanowanie ich preferencji, potrzeb i wartości (patrz rozdz. 7.2) [326,1008,1009].…”

“…Personel medyczny działający w ramach wielodyscyplinarnego zespołu może kierować tym interaktywnym procesem, w którym komunikacja, zaufanie oraz wzajemny szacunek sprzyjają zaangażowaniu pacjenta w leczenie [1021]. Wspólne podejmowanie decyzji należy traktować jako rutynowy element procesu podejmowania decyzji [747], wspieranego przez odpowiednie narzędzia decyzyjne [1022]. Obecnie dostępne są modele opieki zapewniające integrację edukacji, angażowania pacjentów i wspólnego podejmowania decyzji [1023], które mogą mieć szczególną wartość w leczeniu AF.…”

Within‐the‐Clinic Shared Decision for an Over‐the‐Counter Medication

“…Examples have been studied in a variety of cardiovascular diseases, including atrial fibrillation,12 diabetes,9 and coronary artery disease 13. The AHA endorsed the importance of shared decision making in a scientific statement focused on advanced heart failure 14.…”

“…The AHA endorsed the importance of shared decision making in a scientific statement focused on advanced heart failure 14. A wide range of decision aid formats have been utilized, including interactive web‐based tools,15 pamphlets,9 pictographs,12, 13 and mobile apps. Specific to preventive aspirin use, the Mayo Clinic has free downloadable decision aids to be used during an office visit 15.…”