In a heart condition called atrial fibrillation, electrical activity in the upper chamber of the heart goes haywire. The squiggly muscle contraction generated does not pump blood effectively. Resulting blood stasis predisposes these patients to blood clots which can break off and reach the brain causing stroke. In these patients with atrial fibrillation, you may be able to prevent stroke by using blood thinning medications. One of these, aspirin, does so by reducing stickiness of platelets which have a major role in clot formation. It generally has low risk of bleeding and does not need monitoring blood tests. Another medication, warfarin, does so by reducing chemical substances involved in clot formation. Warfarin carries a significant risk of bleeding, especially with injuries, and a blood test has to be done regularly to ensure a safe dose of warfarin. Warfarin is more effective than aspirin for reducing the chances of clot (and stroke) while there is a higher risk of bleeding.
Which one do you choose?
It is a complicated decision. Not everyone has the same risk of stroke with atrial fibrillation. So a risk-benefit assessment is employed. In lower risk patients aspirin is preferred while warfarin is used in higher risk patients. It turns out age and certain comorbidities accurately determine risk. In clinical practice, there is a scoring system called CHADS2 which gives certain points for these characteristics and overall score is used for treatment decision:
Score 0: Give nothing or aspirin
Score 1: Use aspirin or warfarin
Score 2-6: Use warfarin
Let's say my patient scores 2. Untreated, the annual risk of stroke is 4%. Aspirin use reduces annual risk to 2.5% and warfarin to 2%. Is warfarin use a risk worth taking for 0.5% risk reduction? Does the study that came up with these results take into consideration peculiar circumstances of my patients: bumpy roads where you routinely levitate few inches out of your seats stretching blood vessels in the brain, need to climb trees to fetch fodder for cattles, availability of money to do blood tests, availability of blood tests nearby,...the list goes on. All these factors make warfarin a risky choice because of increased likelihood of life threatening bleeds. But is the risk justified for the benefits?
If this exercise has been confusing, it indeed is. You hope and pray your doctor has done this exercise for you.
I do routinely see atrial fibrillation patients taking warfarin at my hospital's outpatient clinic. When I ask them why they are on it, many of them answer their doctor asked them to take it or they were discharged with this medication after the hospital admission. They faithfully do blood test (which is required every 2 weeks many a time) and come for warfarin dose adjustment. If you allow, I would venture a guess that my patients have no idea about above risk-benefit calculation (if it has ever been done). But they are doing it because their doctor told them to, that it may be good for their well-being and longevity.
This is just an example. Our clinics abound with patients suffering from non-communicable chronic illnesses. The treatment decisions entail risk-benefit calculations. What is the potential long-term benefit? What are the potential risks? These are more or less abstract notions both for patients and doctors but especially for patients. A patient with high blood pressures is treated to reduce the risk of heart attack, stroke, in future. Why should one agree to take medications daily for something that one cannot feel? What are these patients actually taking medications for? Are they calculating their risks? Many of my patients don't even know that high blood pressures can increase the risk of heart attack. They have been taking medications because they reduce the blood pressures to normal values. How did these abstract notions about benefits of normalizing blood pressures come? Is it a transmitted knowledge from others experiences? Is it a transmitted notion of benefits of their doctors?
Whatever it is, it expresses as a faith in doctor's recommendation in my day-to-day patients. However much we hear about increasing lack of trust between doctor and patient in our debates, in daily doctor-patient interactions, most of the decisions are done by reflexive trust of patients to their doctors. When I think about it, as a doctor, it is an overwhelming responsibility, to deliver to that trust.
Especially humbling in the setup I work is the fact that our power structure is oblivious about this responsibility. Rather, I sense a feeling of entitlement among us doctors and administrators who hold the power. It is not uncommon to hear, in one of our grand eloquence, that the root of the problem in several of our disorganized institutions is illiterate, irresponsible janata (people) behaving haphazardly. We can elaborate on every solution that does not involve ourselves. As I see a swathe of patients navigating the torturous disorganization of a public hospital just to see a doctor who will tweak their cholesterol medications, I have been increasingly disillusioned about the idea that our patients are illiterate. It is time that our doctors be literate.
Which one do you choose?
It is a complicated decision. Not everyone has the same risk of stroke with atrial fibrillation. So a risk-benefit assessment is employed. In lower risk patients aspirin is preferred while warfarin is used in higher risk patients. It turns out age and certain comorbidities accurately determine risk. In clinical practice, there is a scoring system called CHADS2 which gives certain points for these characteristics and overall score is used for treatment decision:
Score 0: Give nothing or aspirin
Score 1: Use aspirin or warfarin
Score 2-6: Use warfarin
Let's say my patient scores 2. Untreated, the annual risk of stroke is 4%. Aspirin use reduces annual risk to 2.5% and warfarin to 2%. Is warfarin use a risk worth taking for 0.5% risk reduction? Does the study that came up with these results take into consideration peculiar circumstances of my patients: bumpy roads where you routinely levitate few inches out of your seats stretching blood vessels in the brain, need to climb trees to fetch fodder for cattles, availability of money to do blood tests, availability of blood tests nearby,...the list goes on. All these factors make warfarin a risky choice because of increased likelihood of life threatening bleeds. But is the risk justified for the benefits?
If this exercise has been confusing, it indeed is. You hope and pray your doctor has done this exercise for you.
I do routinely see atrial fibrillation patients taking warfarin at my hospital's outpatient clinic. When I ask them why they are on it, many of them answer their doctor asked them to take it or they were discharged with this medication after the hospital admission. They faithfully do blood test (which is required every 2 weeks many a time) and come for warfarin dose adjustment. If you allow, I would venture a guess that my patients have no idea about above risk-benefit calculation (if it has ever been done). But they are doing it because their doctor told them to, that it may be good for their well-being and longevity.
This is just an example. Our clinics abound with patients suffering from non-communicable chronic illnesses. The treatment decisions entail risk-benefit calculations. What is the potential long-term benefit? What are the potential risks? These are more or less abstract notions both for patients and doctors but especially for patients. A patient with high blood pressures is treated to reduce the risk of heart attack, stroke, in future. Why should one agree to take medications daily for something that one cannot feel? What are these patients actually taking medications for? Are they calculating their risks? Many of my patients don't even know that high blood pressures can increase the risk of heart attack. They have been taking medications because they reduce the blood pressures to normal values. How did these abstract notions about benefits of normalizing blood pressures come? Is it a transmitted knowledge from others experiences? Is it a transmitted notion of benefits of their doctors?
Whatever it is, it expresses as a faith in doctor's recommendation in my day-to-day patients. However much we hear about increasing lack of trust between doctor and patient in our debates, in daily doctor-patient interactions, most of the decisions are done by reflexive trust of patients to their doctors. When I think about it, as a doctor, it is an overwhelming responsibility, to deliver to that trust.
Especially humbling in the setup I work is the fact that our power structure is oblivious about this responsibility. Rather, I sense a feeling of entitlement among us doctors and administrators who hold the power. It is not uncommon to hear, in one of our grand eloquence, that the root of the problem in several of our disorganized institutions is illiterate, irresponsible janata (people) behaving haphazardly. We can elaborate on every solution that does not involve ourselves. As I see a swathe of patients navigating the torturous disorganization of a public hospital just to see a doctor who will tweak their cholesterol medications, I have been increasingly disillusioned about the idea that our patients are illiterate. It is time that our doctors be literate.
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