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. 2001 Sep;10(Suppl 1):i19–i22. doi: 10.1136/qhc.0100019..

Importance of risk communication and decision making in cardiovascular conditions in older patients: a discussion paper

N Dudley
PMCID: PMC1765741  PMID: 11533433

Abstract

Atrial fibrillation and aortic stenosis commonly present doctors and patients with difficult decisions about the risks and benefits of treatment options and are both often inappropriately undertreated. Patients may be confused by risk information and doctors may be aware of patients' limitations and use this to manipulate choices to the ones desired by the doctors. This paper examines the importance of risk communication and discusses difficulties that can arise in decision making in these two common cardiovascular conditions.

Key Words: patient preference; risk; informed choice; decision making; patient-caregiver communication; geriatrics

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Selected References

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  1. Abdul-Hamid A. R., Mulley G. P. Why do so few older people with aortic stenosis have valve replacement surgery? Age Ageing. 1999 May;28(3):261–264. doi: 10.1093/ageing/28.3.261. [DOI] [PubMed] [Google Scholar]
  2. Bamford J., Sandercock P., Dennis M., Warlow C., Jones L., McPherson K., Vessey M., Fowler G., Molyneux A., Hughes T. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry. 1988 Nov;51(11):1373–1380. doi: 10.1136/jnnp.51.11.1373. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Coulter A. Paternalism or partnership? Patients have grown up-and there's no going back. BMJ. 1999 Sep 18;319(7212):719–720. doi: 10.1136/bmj.319.7212.719. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Edwards A., Elwyn G. Understanding risk and lessons for clinical risk communication about treatment preferences. Qual Health Care. 2001 Sep;10 (Suppl 1):i9–13. doi: 10.1136/qhc.0100009... [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Gage B. F., Boechler M., Doggette A. L., Fortune G., Flaker G. C., Rich M. W., Radford M. J. Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. Stroke. 2000 Apr;31(4):822–827. doi: 10.1161/01.str.31.4.822. [DOI] [PubMed] [Google Scholar]
  6. Gilbert T., Orr W., Banning A. P. Surgery for aortic stenosis in severely symptomatic patients older than 80 years: experience in a single UK centre. Heart. 1999 Aug;82(2):138–142. doi: 10.1136/hrt.82.2.138. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Hart R. G., Benavente O., McBride R., Pearce L. A. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999 Oct 5;131(7):492–501. doi: 10.7326/0003-4819-131-7-199910050-00003. [DOI] [PubMed] [Google Scholar]
  8. Hart R. G., Boop B. S., Anderson D. C. Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke. 1995 Aug;26(8):1471–1477. doi: 10.1161/01.str.26.8.1471. [DOI] [PubMed] [Google Scholar]
  9. He J., Whelton P. K., Vu B., Klag M. J. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. JAMA. 1998 Dec 9;280(22):1930–1935. doi: 10.1001/jama.280.22.1930. [DOI] [PubMed] [Google Scholar]
  10. Howitt A., Armstrong D. Implementing evidence based medicine in general practice: audit and qualitative study of antithrombotic treatment for atrial fibrillation. BMJ. 1999 May 15;318(7194):1324–1327. doi: 10.1136/bmj.318.7194.1324. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Jørgensen H. S., Nakayama H., Reith J., Raaschou H. O., Olsen T. S. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke. 1996 Oct;27(10):1765–1769. doi: 10.1161/01.str.27.10.1765. [DOI] [PubMed] [Google Scholar]
  12. Kalra L., Yu G., Perez I., Lakhani A., Donaldson N. Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness. BMJ. 2000 May 6;320(7244):1236–1239. doi: 10.1136/bmj.320.7244.1236. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Lamassa M., Di Carlo A., Pracucci G., Basile A. M., Trefoloni G., Vanni P., Spolveri S., Baruffi M. C., Landini G., Ghetti A. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke. 2001 Feb;32(2):392–398. doi: 10.1161/01.str.32.2.392. [DOI] [PubMed] [Google Scholar]
  14. Lip G. Y., Beevers D. G., Coope J. R. ABC of atrial fibrillation. Atrial fibrillation in general and hospital practice. BMJ. 1996 Jan 20;312(7024):175–178. doi: 10.1136/bmj.312.7024.175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Lip G. Y., Golding D. J., Nazir M., Beevers D. G., Child D. L., Fletcher R. I. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract. 1997 May;47(418):285–289. [PMC free article] [PubMed] [Google Scholar]
  16. Lloyd A. J. The extent of patients' understanding of the risk of treatments. Qual Health Care. 2001 Sep;10 (Suppl 1):i14–i18. doi: 10.1136/qhc.0100014... [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Monette J., Gurwitz J. H., Rochon P. A., Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners. J Am Geriatr Soc. 1997 Sep;45(9):1060–1065. doi: 10.1111/j.1532-5415.1997.tb05967.x. [DOI] [PubMed] [Google Scholar]
  18. O'Keefe J. H., Jr, Vlietstra R. E., Bailey K. R., Holmes D. R., Jr Natural history of candidates for balloon aortic valvuloplasty. Mayo Clin Proc. 1987 Nov;62(11):986–991. doi: 10.1016/s0025-6196(12)65068-x. [DOI] [PubMed] [Google Scholar]
  19. Otto C. M. Aortic stenosis--listen to the patient, look at the valve. N Engl J Med. 2000 Aug 31;343(9):652–654. doi: 10.1056/NEJM200008313430910. [DOI] [PubMed] [Google Scholar]
  20. Pathy M. S. Cardiac surgery in elderly patients: benefits and resource priorities. Heart. 1999 Aug;82(2):121–122. doi: 10.1136/hrt.82.2.121. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Protheroe J., Fahey T., Montgomery A. A., Peters T. J. The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis. BMJ. 2000 May 20;320(7246):1380–1384. doi: 10.1136/bmj.320.7246.1380. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Prêtre R., Turina M. I. Cardiac valve surgery in the octogenarian. Heart. 2000 Jan;83(1):116–121. doi: 10.1136/heart.83.1.116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Rodgers H., Sudlow M., Dobson R., Kenny R. A., Thomson R. G. Warfarin anticoagulation in primary care: a regional survey of present practice and clinicians' views. Br J Gen Pract. 1997 May;47(418):309–310. [PMC free article] [PubMed] [Google Scholar]
  24. Sandercock P., Bamford J., Dennis M., Burn J., Slattery J., Jones L., Boonyakarnkul S., Warlow C. Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project) BMJ. 1992 Dec 12;305(6867):1460–1465. doi: 10.1136/bmj.305.6867.1460. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Selnes O. A., McKhann G. M. Coronary-artery bypass surgery and the brain. N Engl J Med. 2001 Feb 8;344(6):451–452. doi: 10.1056/NEJM200102083440609. [DOI] [PubMed] [Google Scholar]
  26. Selzer A. Changing aspects of the natural history of valvular aortic stenosis. N Engl J Med. 1987 Jul 9;317(2):91–98. doi: 10.1056/NEJM198707093170206. [DOI] [PubMed] [Google Scholar]
  27. Smithard D. G., Perez I., Kalra L. Secular trends in the management of hypertension and atrial fibrillation in patients presenting with stroke. QJM. 2000 Jan;93(1):41–44. doi: 10.1093/qjmed/93.1.41. [DOI] [PubMed] [Google Scholar]
  28. Sprigings D. C., Forfar J. C. How should we manage symptomatic aortic stenosis in the patient who is 80 or older? Br Heart J. 1995 Nov;74(5):481–484. doi: 10.1136/hrt.74.5.481. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Stuart G. Government wants patient partnership to be integral part of NHS. BMJ. 1999 Sep 18;319(7212):788–788. doi: 10.1136/bmj.319.7212.788b. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Sudlow M., Thomson R., Kenny R. A., Rodgers H. A community survey of patients with atrial fibrillation: associated disabilities and treatment preferences. Br J Gen Pract. 1998 Nov;48(436):1775–1778. [PMC free article] [PubMed] [Google Scholar]
  31. Sudlow M., Thomson R., Thwaites B., Rodgers H., Kenny R. A. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet. 1998 Oct 10;352(9135):1167–1171. doi: 10.1016/S0140-6736(98)01401-9. [DOI] [PubMed] [Google Scholar]
  32. Unsworth-White J. Cardiac surgery for the elderly: a surgeon's perspective. Heart. 1999 Aug;82(2):125–125. doi: 10.1136/hrt.82.2.125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Wheeldon N. M., Tayler D. I., Anagnostou E., Cook D., Wales C., Oakley G. D. Screening for atrial fibrillation in primary care. Heart. 1998 Jan;79(1):50–55. doi: 10.1136/hrt.79.1.50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Wolf P. A., Abbott R. D., Kannel W. B. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991 Aug;22(8):983–988. doi: 10.1161/01.str.22.8.983. [DOI] [PubMed] [Google Scholar]
  35. Wong J. B., Salem D. N., Pauker S. G. You're never too old. N Engl J Med. 1993 Apr 1;328(13):971–975. doi: 10.1056/NEJM199304013281319. [DOI] [PubMed] [Google Scholar]

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