Wonderful and informative summary and commentary, per usual. This highlights for me the gulf btw biologic plausibility and “extrapolation”, Vs actual evidence. Of course, clinical scenarios require clinical decisions, and the vast majority of those scenarios will not be mappable directly onto any clinical trial evidence. So decisions mad…
Wonderful and informative summary and commentary, per usual. This highlights for me the gulf btw biologic plausibility and “extrapolation”, Vs actual evidence. Of course, clinical scenarios require clinical decisions, and the vast majority of those scenarios will not be mappable directly onto any clinical trial evidence. So decisions made using imperfect evidence is the norm. But the issue is one you’ve often spoken of, that of dogma, and the presumption of having “the right answer” absent evidence, and the further therapeutic fashion that promotes uniformity even in the absence of evidence. Individual patients require individualized decisions, not cookbook answers based on population averages from studies not of direct relevance and applicability. Latter day guidelines in many cardiology domains come to mind.
I had to chuckle at the recent ESC cardiomyopathy guideline, wrt SCD prevention in HCM, and calling out the evidence-free (or at least evidence-poor) reliance on apical aneurysms, LGE, and low EF, espoused by the last AHA guidelines.
As for this study, this changes my practice today. And now it makes me wonder about de novo starts in older frail patients with new AF, as to which form of OAC to choose. Yet another of those evidence free zones.
Wonderful and informative summary and commentary, per usual. This highlights for me the gulf btw biologic plausibility and “extrapolation”, Vs actual evidence. Of course, clinical scenarios require clinical decisions, and the vast majority of those scenarios will not be mappable directly onto any clinical trial evidence. So decisions made using imperfect evidence is the norm. But the issue is one you’ve often spoken of, that of dogma, and the presumption of having “the right answer” absent evidence, and the further therapeutic fashion that promotes uniformity even in the absence of evidence. Individual patients require individualized decisions, not cookbook answers based on population averages from studies not of direct relevance and applicability. Latter day guidelines in many cardiology domains come to mind.
I had to chuckle at the recent ESC cardiomyopathy guideline, wrt SCD prevention in HCM, and calling out the evidence-free (or at least evidence-poor) reliance on apical aneurysms, LGE, and low EF, espoused by the last AHA guidelines.
As for this study, this changes my practice today. And now it makes me wonder about de novo starts in older frail patients with new AF, as to which form of OAC to choose. Yet another of those evidence free zones.