Atrial fibrillation (AF) is the most common heart rhythm disorder seen in adults. Although it is often treatable, undiagnosed or poorly managed atrial fibrillation can have devastating consequences, including stroke, heart failure and, in some cases, death. From a medico-legal perspective, atrial fibrillation is also a condition that frequently features in medical negligence claims because there are well-established national guidelines governing its diagnosis and management.
What is atrial fibrillation?
In a healthy person, electrical signals travel through the heart in an organised manner, causing it to beat regularly and efficiently. When someone experiences atrial fibrillation, the electrical activity within the upper chambers of the heart (the atria) becomes chaotic. This causes the heart to beat irregularly and often more rapidly than normal.
Some patients with AF have symptoms such as palpitations, breathlessness, dizziness, chest discomfort, fatigue or blackouts. Others have no symptoms at all and may only be diagnosed during a routine examination when an irregular pulse is detected. NICE recommends that people with a suspected irregular heartbeat should undergo pulse assessment and an electrocardiogram (ECG) to confirm the diagnosis.
Why does atrial fibrillation increase the risk of stroke?
The greatest danger associated with atrial fibrillation is its link to stroke. AF results in a fivefold increase in the risk of stroke and 20 to 25% of all strokes are caused by AF. Furthermore, AF-related strokes can be more severe compared to other stroke aetiologies.
When the atria are not contracting properly, blood can stagnate within the heart. Stagnant blood is more likely to clot. If a clot forms and subsequently travels from the heart to the brain, it can block a blood vessel and cause an ischaemic stroke. Strokes associated with atrial fibrillation are often severe and can result in permanent disability, cognitive impairment, loss of independence or death. For this reason, stroke prevention is a central element of AF management. NICE recommends formal assessment of stroke risk using the CHA₂DS₂-VASc scoring system and advises that many patients at increased risk should be offered anticoagulant medication to reduce the likelihood of blood clot formation.
How can atrial fibrillation damage the heart?
Atrial fibrillation can also place considerable strain on the heart itself. If the heart beats too quickly for prolonged periods, the heart muscle may become weakened. This can lead to heart failure, a condition in which the heart is unable to pump blood efficiently around the body. Patients may develop worsening breathlessness, reduced exercise tolerance, swelling of the legs and persistent fatigue. Early identification and treatment of atrial fibrillation can often reduce these risks and improve long-term cardiac health.
How should a GP manage atrial fibrillation?
General practitioners play a crucial role in diagnosing and managing atrial fibrillation. A GP should consider the diagnosis in patients presenting with symptoms such as palpitations, dizziness, breathlessness, chest discomfort, or unexplained collapse. An irregular pulse should prompt further investigation, usually with an ECG. Once AF has been diagnosed, management commonly involves assessing both stroke risk and bleeding risk. Patients at significant risk of stroke should generally be offered anticoagulant therapy unless there is a clear contraindication. NICE guidance emphasises that, for many patients, the benefits of anticoagulation outweigh the risks of bleeding. A GP should also consider measures to control the heart rate, assess underlying causes, arrange appropriate investigations, monitor symptoms, and refer patients to specialist cardiology services where necessary. Ongoing review is important because a patient’s risk profile may change over time.
What happens if atrial fibrillation is left untreated?
Untreated atrial fibrillation can expose patients to avoidable risks. The most serious complication is stroke, but patients may also suffer transient ischaemic attacks (mini-strokes), heart failure, deterioration in quality of life and progressive cardiac damage. Importantly, many of these complications can potentially be prevented through timely diagnosis, appropriate anticoagulation and adequate follow-up care. This is why failures in the management of atrial fibrillation can sometimes form the basis of a medical negligence claim.
Where can breaches of duty occur?
Whether a healthcare provider has breached their duty of care depends on the specific facts of each case. However, common allegations in atrial fibrillation claims include failure to diagnose the condition, delays in arranging appropriate investigations, failure to recognise an irregular pulse, failure to initiate anticoagulation when clinically indicated, inadequate monitoring, or failure to refer a patient for specialist assessment. For example, a patient may repeatedly present with palpitations and dizziness but not undergo an ECG. Alternatively, a diagnosis of atrial fibrillation may be made but no formal stroke risk assessment is carried out, and anticoagulation is not offered despite national guidance suggesting that it should be. In other cases, test results identifying AF may not be acted upon appropriately.
The existence of a breach of duty is ordinarily determined through independent expert evidence from a GP, cardiologist or other relevant specialist who assesses the care against the standards expected of a reasonably competent practitioner at the relevant time.
What injuries can result from breaches?
In legal claims, proving a breach of duty is only part of the process. It must also be shown that the breach caused avoidable injury. The most common causative injury is stroke. If a patient should have received anticoagulation but did not, expert evidence may conclude that timely treatment would probably have prevented the stroke. Depending on severity, the consequences can include paralysis, speech difficulties, memory impairment, visual problems and loss of independence. Other potentially compensable injuries may include heart failure, deterioration in cardiac function, recurrent hospital admissions, psychological injury and, in the most serious cases, premature death. The critical question is whether earlier diagnosis or treatment would have made a material difference to the outcome on the balance of probabilities.
Case study
Penningtons Manches Cooper’s medical negligence team investigated a claim on behalf of a patient who was diagnosed with AF and referred for a cardiology expert opinion but not started on anticoagulants. All relevant medical records were obtained from the GP surgery, hospital, and specifically the treating stroke physicians and cardiologists and a detailed witness statement was taken from the patient. The team also obtained independent expert evidence from GP, stroke medicine, and cardiology experts.
The GP expert was critical of the care the patient received after AF was confirmed on the 24-hour ECG. They advised that the patient’s GP should have carried out formal assessments of stroke risk and bleeding risk when the ECG results were reviewed and concluded that the patient’s stroke risk score was high enough, and bleeding risk low enough, that anticoagulant treatment should have been offered at that stage. No responsible body of GPs would support the failure to carry out those assessments and offer anticoagulation. The GP expert therefore identified a breach of duty of the care owed to the patient in relation to the management of AF and considered that referral to cardiology alone was not sufficient. The case on causation was that had the patient been on anticoagulants, the multiple strokes suffered would on the balance of probabilities, have been avoided.
The medical negligence team will now investigate the impact of the negligence on this client. Where negligence is proven, compensation is intended to place the injured person, so far as money can, in the position they would have been in had the negligence not occurred. Damages may include compensation for pain, suffering and loss of amenity, together with financial losses such as lost earnings, care and assistance, rehabilitation costs, medical expenses, travel expenses, and adaptations to the home. In severe stroke cases, compensation can be substantial, particularly where ongoing care needs and loss of earning capacity are significant.
Partner Alison Johnson, who led the team acting on this case, comments: “Atrial fibrillation is a common but potentially dangerous condition that significantly increases the risk of stroke and heart damage if not properly managed. Modern medical guidance provides clear pathways for diagnosis, risk assessment, and treatment, particularly in relation to anticoagulation. Where healthcare professionals fail to recognise, investigate or appropriately treat atrial fibrillation, patients can suffer life-changing consequences. In cases where those failures amounted to a breach of duty, compensation may be recoverable for the injuries that followed.”
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