The fiftysomething police chief had already had a stroke by the time he came to see cardiologist Jacob Haft, MD.
The patient had been treated at a local hospital and then discharged with all 40 pages of his inpatient record in hand. Thumbing through this file, Dr. Haft, who practices at Hackensack University Medical Center (UMC) in New Jersey, discovered something of interest. “I found that he had an episode of 30 minutes of atrial fibrillation at one point during his hospitalization,” Dr. Haft said. “I realized that this intermittent atrial fibrillation had probably played a role in his stroke. Subsequently we anticoagulated him and he's been fine.”
The process of diagnosis and treatment sounds simple, but unfortunately, many atrial fibrillation patients are not handled as well. “Over 50% of atrial fibrillation patients across the country do not receive evidence-based anticoagulation therapy,” said ACP Member Amir Jaffer, MD, chief of hospital medicine at the University Of Miami Miller School of Medicine in Florida.
This failure to treat has serious consequences for patients. “Twenty percent of all strokes are due to atrial fibrillation and up to 60% of these are preventable,” according to the ACP Foundation's Initiative on Atrial Fibrillation and Stroke Prevention.
The initiative was launched earlier this year with the goal of improving those statistics and getting more physicians to recognize and treat at-risk patients like the police chief. The project involves a team approach to optimizing care and includes resources for patients, hospital leaders and out- and inpatient physicians.
“Hospitalists are a key member of the team, since many of the patients will be on the hospitalist service,” said Barbara L. Schuster, MD, MACP, co-chair of the initiative and campus dean at the Georgia Health Sciences University/University of Georgia Medical Partnership in Athens.
Spot the patient
The atrial fibrillation patients that hospitalists see will fall into two major categories, according to initiative co-chair Doron Schneider, MD, FACP, medical director of the Center for Patient Safety and Healthcare Quality at Abington Memorial Hospital in Pennsylvania.
The more obvious group is the patients admitted with atrial fibrillation as their primary diagnosis, who may be suffering from low blood pressure or syncope or heart failure. “Those are a little bit easier to wrap your head around, because you're already concentrating on the cardiac rhythm disturbance,” said Dr. Schneider.
But it's also important to look closely at the patients for whom atrial fibrillation is a secondary diagnosis, he added. “If you come in with another diagnosis like cellulitis and have atrial fibrillation in the background, the hospitalist may be focused on giving the right antibiotics for treating the cellulitis and may not really perceive it as an opportunity to think about the patient holistically and look at atrial fibrillation and the lack of anticoagulation as an opportunity for improvement,” Dr. Schneider said.
Dr. Haft's work on atrial fibrillation has focused particularly on one alternative primary diagnosis: stroke. After the police chief drew his attention to the issue, Dr. Haft began to study the incidence of atrial fibrillation among patients hospitalized for stroke at HackensackUMC. His study, which involved records of almost 1,000 patients, was presented at the International Stroke Conference 2012 in February.
“The numbers are really quite striking. Of the patients over 75 who had ischemic strokes, 46% had evidence of having had atrial fibrillation,” he said. “More striking, among the patients who had evidence of congestive heart failure, 68% of them had evidence of atrial fibrillation.”
The findings confirm existing evidence about the association between atrial fibrillation and stroke and highlight the importance of better recognition and treatment, Dr. Haft concluded.
“Take atrial fibrillation very seriously, especially in the patients who have the risk factors. The risk factors for stroke—heart failure, hypertension, advanced age, diabetes, and coronary disease—are also the risk factors for atrial fibrillation. Atrial fibrillation, permanent or transient and not diagnosed, may be the common mechanism whereby the stroke risk factors cause stroke,” he said. “Don't say, ‘Oh, he had the afib for six hours and we calmed him down and gave him a beta-blocker and it all went away. Let's forget it and hope he doesn't go into it again.’ If they go into it once, they're going to go into it another time and the next time might be associated with a stroke.”
Those stroke patients who don't appear to have atrial fibrillation should be closely watched, too, he advised. “[Physicians] should go out of their way to monitor these patients in the hospital and possibly even monitor them for days to weeks out of the hospital to document the atrial fibrillation if it's there,” Dr. Haft said. “Look for the atrial fibrillation because it might be to their benefit if you can find it and can anticoagulate them.”
Attend to anticoagulation
Optimizing use of anticoagulants in atrial fibrillation is a major focus of the ACP Foundation's initiative. “If you look at what's occurring out there, the appropriate use of blood thinners is not where it needs to be,” said Dr. Schneider. “There was an underappreciation of how much the patient in front of you is actually at risk. If you underestimate the stroke risk and you overestimate the bleeding risk and you're worrying about the medications you have at your disposal, then you are less likely to anticoagulate appropriately.”
Today, however, physicians have access to a number of new atrial fibrillation treatments, including dabigatran, rivaroxaban and possibly soon apixaban. “Hospitalists need to become familiar with each of these new anticoagulants,” said Dr. Jaffer.
The initiative aims to make this task easier; its offerings include a summary of current guidelines on use of the new drugs. To help with decision making about whether to give anticoagulants, the experts also created a decision support worksheet http://www.acphospitalist.org/archives/2012/08/afib1.pdf that addresses stroke, bleeding and fall risk.
Of course, simply prescribing an anticoagulant when it's needed is not sufficient. To ensure optimal results, good patient education and follow up are also required. “The decision to anticoagulate is always a big decision…and the patient has to accept it. The patient needs to have more information about the risk, and the physician more information about how to present this to the patient,” said Dr. Schuster.
To meet these needs, the initiative produced patient education materials, in written form and in videos starring Dr. Schneider. “[They are] for patients who are newly diagnosed, or are confused about the different modalities of therapy, or have questions about lifestyle,” Dr. Schneider said of the online videos.
Confusion and questions can also arise during the handoff of atrial fibrillation care from the hospital to outpatient practice. As for all discharged patients, the scheduling of a follow-up appointment is important, but for those newly placed on anticoagulants, follow-up blood testing is particularly crucial.
“Brokering of that agreement with the receiving office usually takes a phone call to say, ‘Yes, we will accept the responsibility for this blood work and clear documentation of that in discharge instructions to the patient, so he or she knows where to go for the blood work and who's responsible for it. The more clarity you can have around your process, the safer things will be,” said Dr. Schneider.
And safety, of course, is one of the many goals of the Foundation's initiative. “Ultimately, we'd like to see a decrease in stroke. We'd like to see a better informed public, more conversations between patients and their clinical caretakers, and more implementation by institutions of education about atrial fibrillation and stroke prevention,” said Dr. Schuster.