Case report of paroxysmal atrial fibrillation and anticoagulation

Evidence based medicine and narrative based medicine rarely meet, and they may conflict, 1 2 but in clinical care they are complementary.3–5 Some attempts to integrate the two approaches have not considered the doctor's story, which is often critical to understanding a case. 6 7 This paper tries to bridge gaps between a patient's and doctor's narratives and the evidence. It is the story of a patient in our practice (see box) who has produced written narratives about her illness and shared them with her family physician (SR). We use the narratives to decide on the best evidence based treatment for paroxysmal atrial fibrillation after corrected tetralogy of Fallot. We searched Medline between December 1999 and May 2000 with the keywords atrial fibrillation (paroxysmal), tetralogy of Fallot, atrial arrhythmia, anticoagulation, primary care, family medicine, general practice, and ambulatory medicine. We also searched http://www.goldenhour.co.il/ (an Israeli website that includes evidence based medicine). We found no important evidence on the treatment of paroxysmal atrial fibrillation plus tetralogy of Fallot. Our discussion is based on the evidence available on paroxysmal atrial fibrillation alone. Risk factors for thromboembolism in paroxysmal atrial fibrillation are cumulative.8–13 In patients without risk factors who are not treated for thromboembolism, the annual risk of stroke is about 1%. For patients at low risk of thromboembolism, aspirin or no drug is recommended. 8 11–14 The presence of one risk factor puts patients at moderate risk of thromboembolism (2-5% annual risk of stroke), and the treatment recommendation is aspirin or warfarin. Patients at high risk—with a 6-12% annual risk of stroke—should be given warfarin. Articles based in primary care lean towards less aggressive diagnostic and therapeutic approaches.15–18 #### Case history A 56 year old married …