Download Case: An ischemic stroke patient has a remote history of atrial

Get With The Guidelines®-Stroke Data Abstraction Scenario #1:
Case: An ischemic stroke patient has a remote history of atrial fibrillation (greater than 5 years
ago). The patient’s admission medications do NOT include an anticoagulant. There is documentation in
the medical record that the patient was on warfarin for a short period of time 5 years ago but has not
been taking warfarin for the past several years and has had no recurrence of atrial fibrillation. There is
no atrial fibrillation documented during the hospitalization and the patient is not discharged on
anticoagulation therapy. The physician documents “H/O AF. Stopped taking warfarin a few years ago. No
recurrence.”
QUESTION: How should the atrial fibrillation medical history and treatment at discharge elements be
answered in the Patient Management Tool?
ANSWER:
Element: Previously known medical hx of: Select ‘Atrial Fib/Flutter’
Explanation: If the patient has ANY prior history of atrial fibrillation OR atrial flutter, even if it is a
remote history OR the patient has undergone a successful procedure for atrial fib/flutter such as
pacemaker placement, ablation or cardioversion the patient is still considered as having a history of
Atrial Fib/Flutter. There are only 2 instances in which you would NOT record a history of Atrial
Fib/Flutter (1) if the episode was transient AND entirely reversible due to thyrotoxicosis or (2) the
episode was within 8 weeks of CABG.
Element: Persistent or Paroxysmal Atrial Fibrillation/Flutter: Select ‘No’
Explanation: The patient did not have documentation of atrial fib/flutter during the hospitalization
Element: If atrial fib/flutter or history of PAF documented, was patient discharged on anticoagulation?
Select ‘No/ND’
For CM/TJC: Reason for Not Prescribing Anticoagulation Therapy at Discharge? Select ‘No’
Explanation: Patients with Atrial fib/flutter are at increased risk for stroke. This includes patients who
have atrial fibrillation or flutter during the hospital stay or patients who have a history of any atrial
fibrillation or flutter including PAF documented in the medical record. The patient in the above example
has a history of atrial fibrillation and the physician’s note is not an acceptable documented
contraindication to anticoagulation therapy now that the patient has suffered an ischemic stroke.
Numerous questions have been sent to the Get With The Guidelines team questioning patients’ needs
for anticoagulation therapy when there is no current evidence of atrial fibrillation (AF) OR successful
treatment resulting in maintenance on sinus rhythm has occurred (e.g. catheter ablation). Even in
patients who have undergone catheter ablation therapy there is uncertainty as to what the risk of
recurrence of AF is over the long term; AF can recur without symptoms and be unrecognized by the
patient or physician. Due to the high rate of silent recurrent of AF with its attendant embolic risk,
ideally, anticoagulation should be maintained in all patients with stroke and a history of AF, regardless of
whether sinus rhythm is achieved. Even in stroke patients who have undergone past catheter ablation
therapy or surgical MAZE there is uncertainty as to what the risk of recurrence of AF is over the long
term, and anticoagulation therapy would be indicated.