Thursday, June 28, 2012

Rhythm or rate control for atrial fibrillation?

- Kenny Lin, MD

For many years, the standard thinking regarding treatment of patients with atrial fibrillation was that drug therapy to restore sinus rhythm (rhythm control) was superior to drug therapy to slow the ventricular response rate (rate control). That all changed in 2002, when a clinical trial found no difference in survival between patients randomized to rhythm or rate control, and a higher incidence of adverse effects in the rhythm control group.

This trial and other evidence led the American Academy of Family Physicians to issue a guideline that recommended rate control with chronic anticoagulation as the preferred strategy for most patients with atrial fibrillation. A recent AFP review article echoed this guidance, assigning an "A" strength of evidence rating to the following statement:  "Rate control is the recommended treatment strategy in most patients with atrial fibrillation. Rhythm control is an option for patients in whom rate control is not achievable or who remain symptomatic despite rate control."

On occasion, however, evidence-based interventions achieve different results in primary care than in clinical trials. A study published earlier this month in the Archives of Internal Medicine used administrative databases in Quebec, Canada to compare mortality between older patients with atrial fibrillation who were initially prescribed rhythm or rate control therapy after their diagnoses. After experiencing similar mortality through 4 years of follow-up, patients in the rhythm control group had a significantly lower risk of death, with 23% lower relative mortality than patients in the rate control group at 8 years. These surprising results beg the question: was this new study somehow flawed? If not, as the subtitle of an accompanying editorial asked, can observational data trump randomized trial results?

Although it is unlikely that treatment guidelines will change any time soon, this study should remind clinicians that management of patients with newly diagnosed atrial fibrillation should be individualized, and the risks and benefits of different strategies discussed in detail before making treatment decisions.

Monday, June 25, 2012

Family physicians and Communities of Solution

Every so often, AFP reviews a public health topic, such as outdoor air pollutants, disaster preparedness and response, or reducing the effects of climate change. And occasionally we receive feedback from readers who suggest that these topics are not appropriate for a family medicine journal, since family physicians are practicing clinicians who provide direct care to individual patients, not public health professionals responsible for large populations. However, this view of the limited role of family physicians is by no means unanimous.

In response to concerns about the shrinking scope of family medicine, Dr. Joseph Scherger wrote on the Society of Teachers of Family Medicine blog that "family medicine today is more complex and expansive in some ways than ever before." Family physicians must learn advanced motivational counseling and information management skills to practice excellent preventive and chronic care. Also, the patient-centered medical home requires family physicians to take population-based approaches to managing chronic illnesses.

In March, the Institute of Medicine published a report on opportunities for integrating primary care and public health. Notably, the report did not advocate for large numbers of family physicians to obtain formal public health degrees. Just as an editorial in the Annals of Internal Medicine argued that the subspecialty of geriatric medicine would be best served by incorporating its unique resources and skills into primary care training, a group of family medicine leaders convened by the American Board of Family Medicine recently declared:

The modern primary care physician, who values “community participation, political involvement, and collective advocacy," can, in effect, be a true public health professional, forming partnerships with community-based organizations that facilitate healthy change. This paradigm shift includes the transition from treating individuals in isolation to treating people in the context of their lives in their communities, indeed, culminating in community-centered care.

In a publication in the Annals of Family Medicine, this group re-examined and updated the 1967 Folsom Report, which provided a blueprint for connecting the personal physician with community resources in "Communities of Solution." What do you think of this ambitious vision of the family physician as a public health professional? Is this a desirable goal, and if so, what would it take to achieve it?