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What does the NICE atrial fibrillation guidance hold for GPs?

New NICE clinical guidance on atrial fibrillation means a major shift in the management of the condition. Read what the critical issues are for GPs

What are the key changes?

The main changes for GPs are in stroke prevention:

  • CHADS2 should no longer be used. GPs should now use the CHA2DS2-VASc score to assess stroke risk – and offer anticoagulation to men with a score above 0, and women with a score above 1.
  • Aspirin should no longer be offered solely for stroke prevention. Only continue aspirin if a patient is on it for another reason, ie, for occlusive vascular disease and is at low risk of stroke, or does not want to start on anticoagulation, or is advised to continue on aspirin as well as anticoagulation by a cardiologist, eg as part of dual or triple antithrombotic therapy following coronary stenting
  • Anticoagulation therapy can be with warfarin, another vitamin K antagonist, or one of the new oral anticoagulants – dabigatran, rivaroxaban or apixaban.
  • GPs should also use the HAS-BLED score to assess bleeding risk in patients going on anticoagulation therapy, and to monitor modifiable risk factors including high blood pressure, poor INR control and harmful alcohol consumption
  • For patients on warfarin, they should now have their time in therapeutic range (TTR) calculated at each visit and dosing adjusted accordingly. If poor anticoagulation control cannot be improved, discuss an alternative anticoagulant with the patient.

Why have the changes been made?

The new guidelines bring NICE up to date with the latest evidence and mean it is now more closely aligned with European Society of Cardiology guidance and the Royal College of Physicians National Clinical Guidelines for Stroke.

In particular, the CHA2DS2-VASc score is more accurate than CHADS2 at identifying those patients who are truly at low risk and do not need anticoagulation therapy.

Also it has been established for several years that aspirin is just as likely to cause bleeding as oral anticoagulants but offers far inferior protection from stroke.

What are GPs’ concerns?

Workload – GP leaders say practices are already at capacity and the additional work involved in bringing management of atrial fibrillation up to date in accordance with the guidelines is not funded through the core contract. Although some changes will be incorporated into QOF eventually, they argue the new guidelines are much more complex and should be supported through enhanced services – or there is a risk GPs will have to refer on to secondary care.

Also, CCGs in many areas are strongly discouraging GPs from using the newer oral anticoagulants. For patients who genuinely cannot cope with taking warfarin to be anticoagulated in line with the guidance, these restrictions may need to be relaxed.

What does NICE say?

For now, GPs should be encouraged to review patients on aspirin opportunistically – for example when they come in for annual reviews of their cardiovascular conditions and other comorbidities.

If they feel the process is unmanageable they should seek additional support and resources from local CCG clinical leads.

NICE has also published guidance for implementing the new recommendations – the NICE Implementation Collaborative consensus statement – with a particular focus on ensuring GPs can prescribe the newer oral anticoagulants where appropriate. The guidance states these drugs ‘should be automatically included in local formularies’.

NICE clinical guideline 180 - The management of atrial fibrillation

Readers' comments (6)

  • Why not ask your local pharmacists to help with this? We could identify and encourage patients to make GP appointments as part of the pharmacy targeted MUR service, and GPs could signpost to pharmacy for the New Medicines Service once anticoagulants have been prescribed. Working collaboratively could help GPs with the workload associated with this change....

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  • Changing medical practice is like steering an oil tanker the risks of aspirin have been known for years yet i spend time battling with vascular colleagues who insist on its use ,even when the patient has reacted !!!

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  • Most practices will have insufficient experience to manage anticoagulation accurately and the idea of cooperation across practices is always a non starter (even within one building)! The pharmacy "clinic" mentioned above is a great solution, a really effective system was introduced in Lewisham a few years back, hopefully it's still running?

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  • Timely advice

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  • The advice is timely but with the cost cutting, where will the money come from?

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  • Open Letter to NICE

    I would like to formally complain about NICE's Guidance releases.

    Again 'GPs are to be tasked with reviewing all their patients with atrial fibrillation who are taking aspirin, under final NICE guidance published today that recommends anticoagulant therapy as the only option for stroke prevention in these patients' (Pulse GP Magazine website 18/6/2014)

    This release was in the newspapers as front line news causing panic in patients.

    There should be a release to GPs and healthcare professionals at least a month before it is released to the general press, to allow time for GPs, CCGs and the DOH to come up with a coherent policy on how to deal with the release in the best interests of patient care so we are prepared.

    In this particular example - an enhanced service or other nationally agreed service requires negotiation and this clearly is not going to happen as patients are already contacting the surgery wanting to know if they can switch to the NOACs and the cost implications to the CCG budgets are vast.

    Please change your policy on the release of your guidance to allow time fot the medical profession to be prepared for its impact.

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