Stroke awareness: delayed diagnosis of atrial fibrillation and avoidable strokes

Posted: 13/07/2022

Recognition of the signs and symptoms of strokes and the need for prompt action in the face of these signs have received significant public profile in the last few years. However, an area where people are perhaps less aware of a link between action and outcome is atrial fibrillation, in particular, the implications in terms of stroke risk for a patient with undiagnosed or untreated atrial fibrillation.

One of the types of clinical negligence claims involving strokes that the Penningtons Manches Cooper clinical negligence team deals with is negligence surrounding failures to diagnose or properly manage atrial fibrillation and the degree to which that has been a factor in a patient’s later stroke.

Strokes relate to blood flow and supply to the brain and occur when that blood supply is cut off, resulting in a lack of oxygen getting to brain cells – which after a period of time without oxygen effectively die. They can be caused either by blood clotting and blocking vessels (ischaemic stroke) or by the opposite mechanism where there is a haemorrhage and the vessels bringing blood to areas of the brain burst (haemorrhagic stroke). Strokes caused by a clot have a better prognosis with prompt treatment.

It is well known that the consequences of stroke can be life changing. For that reason, both prevention and prompt treatment are important.

How are atrial fibrillation and stroke linked?

Atrial fibrillation is an irregular heart beat caused by abnormal electrical impulses that can result in the development of blood clots in the chambers of the heart. Those blood clots can then leave the heart, pass through the blood circulation and become lodged in the blood vessels in the brain – causing a blockage and an ischaemic stroke. The presence of atrial fibrillation is therefore known to be a risk factor for stroke.

Atrial fibrillation – risk factors and signs

Because of the increased risk of stroke arising from atrial fibrillation, among other things, prompt diagnosis and management is important. Clinicians, particularly GPs, need therefore to be alert to the signs and symptoms of atrial fibrillation.

Risk factors for developing atrial fibrillation include:

• heart disease;
• age (the elderly have a higher likelihood of developing it);
• high blood pressure; and
• high alcohol intake.

The signs and symptoms that should prompt suspicion of atrial fibrillation, particularly in a patient with any of the above risk factors, include:

• fatigue;
• fainting and dizziness;
• palpitations;
• shortness of breath; and
• chest pain.

Atrial fibrillation – diagnosis

Various tests may be carried out on a patient with signs of atrial fibrillation but the usual ones would be either an electrocardiogram or an echocardiogram.

Atrial fibrillation – management

There are two aspects to managing a patient with atrial fibrillation:

• management of the condition itself – because it is caused by abnormal electrical impulses, the aim of treatment is to try to correct those and there are various methods ranging from medication (such as betablockers) to the fitting of a pacemaker; and
• management of the risks created by the atrial fibrillation – at the same time as trying to correct the atrial fibrillation, patients will usually be prescribed anticoagulants to prevent clot formation.

The NICE guidelines on atrial fibrillation mandate consideration of stroke risk and appropriate advice to the patient where atrial fibrillation is diagnosed, and address issues such as anticoagulation management and review. There is plenty of literature available that highlights the need to consider and manage stroke risk in these patients.

Clinical negligence and atrial fibrillation / stroke

As outlined above, the pure fact of the known association between atrial fibrillation and stroke means that any practitioner assessing a patient presenting with signs consistent with the condition, especially if risk factors are present, must consider and arrange an urgent investigation. Should a diagnosis be reached, there needs to be careful consideration of appropriate management and specifically stroke prevention measures.

Claims may be pursued in cases where a diagnosis of atrial fibrillation should have been suspected but was overlooked and only made after the patient suffered an ischaemic stroke as well as where a diagnosis has been made but the follow up management has been inadequate, leaving a patient unaware of the implications of the diagnosis and with no active treatment either of the atrial fibrillation or their stroke risk. These failures have led to them suffering a potentially avoidable stroke.

In other cases, claims may be brought against hospitals. The usual scenario is that a diagnosis is made and plans put in place to start management of the heart rate but, due to a lack of coordination or communication, anticoagulation medication is not started, with a stroke happening in the interim period. Claims then relate to the failure to start anticoagulation in the presence of known and as yet uncontrolled atrial fibrillation.

Why bring a clinical negligence claim?

The impact of a stroke can be far-reaching and in some cases fatal. Where the stroke should have been avoided with appropriate medical care, a successful claim for clinical negligence can make a considerable difference to a claimant who is disabled as a result of the stroke, funding care, equipment, adaptations to accommodation, physiotherapy and general rehabilitation as well as loss of earnings.

Further resources on stroke and atrial fibrillation

Stroke Association website
NICE guidance on atrial fibrillation: diagnosis and management

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