Doctor claims that its negligence if you dont give Coumadin to all A-fib patients

Um, unless you have a convincing reason not to (ie. the risks of anticoagulation are greater than the risk of stroke) then it pretty much is malpractice.

I don't believe that to be absolutely true Seaglass. It is common for a person to flip into A fib maybe only once in their life. In that instance, the chance for someone to form a clot and then embolize that to the brain or elsewhere is pretty slim. For most patients with new onset A fib, I've seen them get TEE (preferred) or TTE and if no clot is seen, then they get rate controlled with a B-Blocker and told to take baby aspirin every day. While I don't have any articles in front of me, I've read a lot recently that rate control has proven more beneficial to patient outcomes that anticoagulation in A Fib patients. Oh yeah, also try and find the reason that someone is in A Fib and correct that (ie low potassium or otherwise).

How about paroxysmal a fib? do these ppl get put on coumadin? I had a pt the other day with paroxysmal a fib from pakistan. she was told she had a fib in pakistan, but there is no documented evidence in the US that she has a fib. she came into the ED the other day with c/o palpitations and dizziness. her rate was like in the 80s and the EKG showed a lot of premature atrial complexes.

Read the AFFIRM trial and all the follow-ups. Even if someone goes into A-fib temporarily, they should be anticoagulated for life. What anticoag is used is a bit more complicated however (warfarin vs ASA vs plavix)

Yeah, you take a BIG gamble (see link above) if you do not place patients WHO ARE IN A-Fib (not were in A-fib, or had A-fib oncein their life) on anticoagulation. One stroke = big lawsuit. I am familiar with studies showing that rate control is more important than rate conversion, but not with any that show rate control to be more important than anticoagulation. Indeed, I don't think you could ethically do a study where you do not anticoagulate one of the study groups.

all a. fib need anticoag.... however if it is paroxysmal a.fib in a young pt. w/out comorbidities you can stick with only aspirin... the studies have born that out...

seaglass, i think you are getting your studies confused.... outcome is better for rate control vs. rhythm control (ie: cardioversion)

That's what I said:

I am familiar with studies showing that rate control is more important than rate conversion,

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Tenesma said:

all a. fib need anticoag.... however if it is paroxysmal a.fib in a young pt. w/out comorbidities you can stick with only aspirin... the studies have born that out...

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It's not true that ALL a-fib needs anticoagulation. You have to weigh the risks and benefits for that particular patient. In a patient who's young (less than about 60), and has a fib with no other risk factors for clots/stroke, their yearly risk of stroke off of coumadin is very low. In these patients, the risk of anticoagulation actually outweighs any benefit they would get, so standard of care is not to anticoagulate them, and just give them aspirin. On the other hand, someone with afib who's over 80 with no other risk factors would definitely benefit from anticoagulation since their yearly risk of stroke is so high (yearly risk in afib goes up with age). However, if that patient falls often, their risks would outweigh the benefit of anticoagulation, and therefore should normally not be given coumadin.

The above are just a couple of examples of when anticoagulation is not indicated in afib. You have to look at the individual patient and what their particular risk factors are before making that decision. There are some good formulas available for the Palm which help you to estimate someone's yearly stroke risk.

As an aside, to avoid getting sued, it's important to document WHY you made the decision you did, whether you give anticoagulation or not. If you have a good reason to support either decision, you will be protected.

I would second AJM's comments. As long as you have a good reason not to start AC, discuss that with the patient and document it, no reason for a lawsuit. If the pt refuses AC, inform the patients of the risks taken and document. It's all about being thorough with the patient and the medical record...

lf

i am sorry i wasn't more specific... all a. fib should be on anticoagulation unless there is a contraindication...

and i agree that documentation is the best thing for a lawsuit

anyone have a link to the palm program that predicts stroke risk???

MacGyver said:

Contraindication is framed in a subjective context. Its easy to find an "expert" doctor who will testify that your "contraindication" was not strong enough to disavow the medication.

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Not necessarily. depends what the c/i is. if your patent had a brain nleed twp weeks before...

my bad... I was tired/hungover when I said rate control over anticoagulation. I should have stated rate control over rhythm conversion.

AJM said:

In a patient who's young (less than about 60), and has a fib with no other risk factors for clots/stroke, their yearly risk of stroke off of coumadin is very low. In these patients, the risk of anticoagulation actually outweighs any benefit they would get, so standard of care is not to anticoagulate them, and just give them aspirin.

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Agreed.
But I am willing to bet that the patients that the OP referred to are not one of the top two ( LOne Afib/Afib w/ RF's) in the figure.

I have only seen one patient in my career that did not have HT, reduced LVEF, or failure, who came in only w/ A-fib.

I have easily seen over 200 that needed coumadin.


FOr you guys, from ACC website:

MustafaMond said:

Agreed.
But I am willing to bet that the patients that the OP referred to are not one of the top two ( LOne Afib/Afib w/ RF's) in the figure.

I have only seen one patient in my career that did not have HT, reduced LVEF, or failure, who came in only w/ A-fib.

I have easily seen over 200 that needed coumadin.


FOr you guys, from ACC website:

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Personally I would guess that the lawsuit probably involved a patient who had contraindications to anticoagulation, but it wasn't documented in the charts as a consideration, so it left the physicians open to getting sued (esp since the pt saw both an internist and a cardiologist - it would be hard for BOTH of them to 1. notice that the pt had afib, and then 2. not anticoagulate him/her, unless they had a good reason not to). Usually with negligence, the failure to anticoagulate happens because no one even notices that the pt has an irregular pulse. But I don't know the details of this particular case...

As an aside, it's interesting that you've only seen 1 pt with lone afib in the past. I have seen several younger patients with lone afib, two of whom are in my continuity clinic, and none of whom I am anticoagulating (although I do make sure I have proper documentation of this, and I discuss the risks/benefits with the patients).

Granted, the vast majority of patients with afib do need anticoagulation, but it's important to remember to "do no harm" - that is, don't give someone a medication that is going to give them more complications than benefits, especially if it's just because a lawyer told you to do so...

Personally I would guess that the lawsuit probably involved a patient who had contraindications to anticoagulation, but it wasn't documented in the charts as a consideration, so it left the physicians open to getting sued (esp since the pt saw both an internist and a cardiologist - it would be hard for BOTH of them to 1. notice that the pt had afib, and then 2. not anticoagulate him/her, unless they had a good reason not to). Usually with negligence, the failure to anticoagulate happens because no one even notices that the pt has an irregular pulse. But I don't know the details of this particular case...

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Actually, in the article the lawyer says that most of the "malpractice" he litigates is miscommunication: the cardiologist thinks the internist will do it (since he will follow the pt's INRs) and the internist thinks the cardiologist will do it (since it's a cards problem). End result - no one does it.

Seaglass said:

Actually, in the article the lawyer says that most of the "malpractice" he litigates is miscommunication: the cardiologist thinks the internist will do it (since he will follow the pt's INRs) and the internist thinks the cardiologist will do it (since it's a cards problem). End result - no one does it.

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Good point -- communication is a huge issue. I would like to give the lawyer the benefit of the doubt by thinking that maybe this was a "real" case where anticoagulation was definitely indicated but not given, but I still get this feeling that the physician made an appropriate decision but without adequate documentation, and just because there was a poor outcome, the lawyer went after him. This is not based on any facts about the case (since I only know what's in the article), but it is based on my bias against malpractice lawyers, and especially on the attitude that the lawyer has in his article. (for example, he spends a great deal of time talking about how he searches out the money-making cases -- not too ethical in my book.)

I guess I haven't seen much lone Afib because I do mostly inpatient IM.

Whenever we choose NOT to go w/ coumadin we make sure to fully document the contraionidcation.

Seaglass said:

Yeah, you take a BIG gamble (see link above) if you do not place patients WHO ARE IN A-Fib (not were in A-fib, or had A-fib oncein their life) on anticoagulation. One stroke = big lawsuit. I am familiar with studies showing that rate control is more important than rate conversion, but not with any that show rate control to be more important than anticoagulation. Indeed, I don't think you could ethically do a study where you do not anticoagulate one of the study groups.

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I agree

I had an elderly alcoholic pt that we decided not to antocoag due to the risk of falls. Studies are terrific, but ya gotta consider the individual.

MacGyver said:

This illustrates the real problem with our court system.

Do you doubt that if I was a lawyer I could drop 50k on a doctor "expert" witness who claims that this decision is malpractice?

Expert witness = for sale to the highest bidder

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Why are you so anti?

We need the courts, and there are problems, but they aren't as bad as they seem.

I know 2 lawyers that deal w/med malpractice. one defends docs, the other prosecutes docs. both say ~80% of all cases are frivolous. Both say if your pt likes/trusts you they are much less likely to prosecute, even if you make a mistake. Own up to it immediately, you'll probably be fine.

Yep, we live in a litigious society. But ya can't let the fear of being sued run your practice. Ya gotta do what's best for the individual. In my case, an EtOH pt who falls and bleeds out due to anticoag is also a lawsuit waiting to happen. And in this case, was judged to be the biggest risk.

I didn't see it mentioned above, so I wanted to add that the series of SPAF (Stroke Prevention in Atrial Fibrillation) studies also support not necessarily prescribing Coumadin for everyone with A.Fib. There's a good table outlining these recommendations in UpToDate, in the articles on the SPAF studies. It essentially involves roughly quantifying a person's other risk factors, as others have described above. Clearly, warfarin is NOT for everyone!

I thought I'd chime in to mention a situation where you wouldn't use coumadin for a-fib.

My mother had a-fib as a result of untreated hyperthyroidism (Graves Disease). She was misdiagnosed and put on beta blockers even though she was incredible shape and had low blood pressure and low cholesterol. Two a-fib episodes and several doctors later, she was finally properly diagnosed and treated and has not had an episode since.

I agree without question that documentation is key.If there is an adverse treatment event the possibility of litigation will always exist. .If you clearly document your thinking process and discussions with the patient you will stand on very strong ground.You can not be expected to guarantee a perfect outcome,only that your care was not negligent.

a) documentation is way key. way. hospitals need to get on their staff to do this religiously, and the staff needs to be fully compliant.

b) where was the PharmD during all this? Isn't this what they exist for? or was it all outpatient?

c) FYI, like 1 of every 10,000 incidents of bona fide negligence on the part of a physician or other hospital staff member resulting in an actionable injury to a patient ever result in the patient receiving the damages for their injury that they sustained. so, while 80%, according to some attorneys' personal observations are frivolous, first off those attorneys have an ethical obligation to not bring a meritless claim, and second, the vulture attorneys who DO bring those 80% of frivolous, meritless claims are like victims who cry rape when there was no rape--they muddy the waters of truth and make it a much more complex situation for docs, hospitals, risk managers, and legislators to understand and to work to fix. i know a few docs who've been sued for malpractice, some legit, others totally under shady circumstances. i also know that juries award damages based in large part on emotion (i.e., have fun if you're a pediatric surgeon, cause you're screwed).

d) the system is a big honkin' mess, and there is so much misinformation floating around it's not even funny. like attempts at "tort reform" limiting damage awards to a certain "capped" amount. they don't do squat. most of the money paid out for malpractice is in the form of out of court settlements that go for $50k or less, since it's cheaper for the med mal insurance co to settle out and lose for 50k than it is to win via litigation which costs, at a minimum, $80k. totally lame.