Volume 3, Number 1, January-February-March 2010

POPULAR
TOPICEDITORIALIf at first you don’t succeed, try, try again!
Professor Michael Kirby

POPULAR
TOPICORIGINAL RESEARCHInvolving patients in decisions about preventive medication: a focus group study
Ian Hill-Smith, Elspeth Mathie, Paul Little

Background: Patients may have unrealistic expectations of preventive treatment and frequently do not take long-term medication. Involvement of the patient in the decision to start such medication may improve this, but enabling an informed decision is notoriously difficult.
Aims: To explore patients’ perceptions of preventive medication, the desire for informed choice and how this could best be achieved.
Method: Purposive sampling was used to select patients registered with one of two general practices in South England. Audio recording, transcription and computer-assisted textual analysis were conducted for focus group discussions.
Results: This was a small study, but the majority of focus group participants who had been prescribed a preventive medication said they received very little or no information about benefits and disadvantages when it was started. Some felt that doctors did not want to share information. Older participants thought that choice was over-rated, trusted their doctor to recommend appropriate medication and did not necessarily wish to be involved in the decision. Younger participants wanted to be more involved. However, even those who expressed little interest in involvement felt that personalised information compared with population norms comparing individuals to the ‘average person’ would be helpful. Written information specific to the individual and on how the medication or lifestyle changes might affect them was considered welcome.
Conclusions: Doctors need to be sensitive to patients’ preferences for involvement in the decision-making process and for the way information on risk is shared. Providing written information specific to the individual patient is likely to facilitate shared decisions about preventive medication.

JOURNAL REVIEWJournal review

POPULAR
TOPICHOT TOPIC REVIEWAtrial fibrillation: which patients should be managed in primary, secondary and tertiary care?
David Jones, Tom Wong, Diana Gorog, Vias Markides

Atrial fibrillation is the commonest sustained cardiac arrhythmia, and has a significant impact on morbidity and mortality. It is a leading cause of stroke, and suitable thromboprophylaxis should be considered in all patients. Treatment is tailored to the individual. This article will review the management strategies for patients with atrial fibrillation, and discuss the roles of primary, secondary, and tertiary care.

GUIDELINESAn international perspective on cardiovascular risk management: recommendations for moderate- to low-risk patients
JI Stewart, E Washbrook, A Tonkin

Assessment of risk factors allows physicians to determine an individual’s cardiovascular risk. The tools used to estimate risk are derived from prospective cohort studies and take into account the intensity of the range of important risk factors. ‘Highrisk’ patients are generally defined as those whose 10-year risk of a coronary event is ≥20%, and include all individuals with established cardiovascular disease. Individuals at lower risk are classified as ‘moderate- to low-risk’, eg, 10-year risk <20% (Table 1). Although such individuals are asymptomatic, they are important targets for primary prevention of cardiovascular disease (CVD), particularly as the first clinical manifestation of coronary heart disease may be fatal. This article provides a concise guide to the management of moderate- to low-risk patients, based on recommendations from some of the most up-to-date clinical practice guidelines for prevention of cardiovascular disease (Box 1).

CASE REVIEWSupraventricular tachycardia: the patient’s perspective
Nicola Jenns

Supraventricular tachycardia (SVT) often begins in childhood or early adulthood. In this review, a patient describes her experience of coping with episodes of SVT and the experience of undergoing cardiac ablation and subsequently having a pacemaker fitted.

THERAPEUTICS REVIEWSmoking cessation 4: antidepressants for smoking cessation – bupropion and nortriptyline
Paul Aveyard, Amanda Parsons, Rachna Begh

Cigarette smoking remains the most preventable cause of illness, death and excess healthcare costs in the UK. Most smokers want to stop smoking and intend to stop at some point. In this fourth article in our occasional series on smoking cessation in primary care, we look at the evidence for the use of antidepressants, including bupropion, which is licensed for this indication, and nortriptyline, which is not.

POPULAR
TOPICPREVENTIONMaking sense of HDL cholesterol
Jonathan Morrell

Lowering LDL cholesterol (LDL-C) with statins for the prevention of cardiovascular disease (CVD) has rightly become a core activity in primary care. However, recognising that the benefits of reducing LDL-C with statins are limited has led to the recognition that the ‘residual risk’ that remains may be modified further by attention to other lipoprotein fractions, particularly HDL cholesterol (HDL-C).

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