AF and dementia

Today’s video is on the subject of AF and dementia

The first thing i want to say is that unfortunately the practice of modern day medicine is largely servile to clinical guidelines. We decide how to treat a patient based on how someone else (i.e whoever wrote the guideline) tells us how to manage the patient. If we stick to the guideline, we feel that we are offering top quality care and we can defend ourself in court. If we don't stick to the guideline then we feel vulnerable to criticism by our own colleagues and also medico-legal lawyers.

Much of the guidelines that are published by august bodies like NICE, are based around an examination of the evidence base to see how beneficial an intervention may be but also how cost effective it may be. If it is not deemed beneficial or cost effective, it is not recommended and unfortunately everyone then believes that it is not worth considering in the patient’s management.

The problem is that guidelines lag several years behind research and therefore when scientists find something important through observation, the first thing they have to do is conduct rigorous experiments to confirm or refute their suspicion, then they have to further confirm this by doing large scale human trials, then they have to publish the data, then if the data are very persuasive a bunch of ‘experts’ get together and decide whether the findings are worthy of changing guidance and then that guidance is published and it can take a few years for that change in guidelines to be adopted as a change in medical practice at grassroots level. The whole process can easily take 10-15 years and therefore patients may continue to be managed in sub-optimal manner for this duration of time even when there is available research to say that things could be done better. As doctors are generally very defensive and not particularly reflective, it is important for patients to be aware of the latest research so that they can advocate for themselves and use any available new research in their decision making process. This is the foundation of patient empowerment. This is why i started this channel. I believe that patients should be equipped with all the information that is out there to allow them to work out the best way they would like their condition to be managed and their doctor’s role is that of the educator and enabler rather that the doctor acting as if they know everything and the patient knows nothing.

Today I wanted to talk about some troubling research in the field of AF.

AF stands for atrial fibrillation. AF is one of the most common heart rhythm disturbances and can affect up to 2% of the population. The big risk of AF is thought to be an increased risk of strokes and therefore when we see patients above the age of 65, or patients who carry co-morbidities we recommend lifelong anticoagulation and as long as the patient is anti-coagulated, we feel that the patient is safe. We never really think beyond the risk of stroke. If the patient is younger than 65 and does not carry comorbidities we don’t anticoagulate them because we believe that the risk of stroke is very low.

However over the past few years there have been several studies which have studied AF patients and discovered patients with AF have a significantly higher prevalence of cognitive impairment and dementia and as we do not have any clinical guidelines as yet, we have to try and work out for ourselves as to why there is this association.