Atrial fibrillation is a common etiology for ischemic stroke. Numerous studies have supported that after an ischemic stroke, extended outpatient cardiac monitoring detects paroxysmal atrial fibrillation in patients in whom atrial fibrillation was not detected on in‐hospital EKG or telemetry. Anticoagulation in these patients offers significant potential for secondary stroke prevention. Implementing this on a broader scale confronts several practical challenges.
At our institution, a 575‐bed community hospital, the two most significant barriers to widespread post‐stroke cardiac monitoring were insurance reimbursement and the presence of multiple different cardiology practices at the hospital. Most insurance companies would not reimburse for the device if placed within the hospital. With multiple cardiology practices, each group had a different referral mechanism, and preferred monitoring devices varied widely. Our practice, which provides the majority of care to stroke patients at the institution, attempted to address these challenges through a simplified hospitalist‐organized referral pathway.
Hospitalists caring for stroke patients individually evaluated patients for a post‐hospitalization cardiac monitor. The main exclusion criteria were an alternative stroke etiology, a pre‐existing indication for anticoagulation or a contraindication to anticoagulation. Appropriate candidates were referred through a case manager to a transitional physician agency, and, to overcome the insurance issue, a home visit was arranged to place a monitoring device. A single device was chosen, a two‐week monitor with asymptomatic atrial fibrillation detection that patients could mail back at the end of their monitoring period. One cardiologist interpreted all device reports, and one hospitalist was responsible for contacting patients with results, and, if needed, arranging appropriate follow‐up. Those with pre‐existing relationships were referred back to their own cardiologist.
To date, 31 patients have been monitored after stroke or transient ischemic attack utilizing this pathway. Twenty‐nine of those 31 patients had met appropriate criteria for monitoring. Two patients had atrial fibrillation detected, both of whom were started on anticoagulation. Two other patients had significant ventricular ectopy warranting cardiology follow‐up.
Our hospitalist‐organized pathway for post‐stroke cardiac monitoring decreased the complexity of making referrals and helped overcome previous barriers confronted when arranging monitoring.