This site is intended for health professionals only

At the heart of general practice since 1960

GPs told to review aspirin use in patients with atrial fibrillation

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.

The new guidance means GPs will need to start advising patients with atrial fibrillation who are on aspirin to stop taking it, and encourage them to take warfarin or one of the newer oral anticoagulants.

NICE said just over a fifth of the UK population with atrial fibrillation – around 200,000 patients – are currently on aspirin, many of whom should be able to be switched onto anticoagulation therapy of some sort.

GP leaders have warned that practices do not have the capacity to proactively call in patients, and suggested that changing management of this number of patients could only be achieved through incentive schemes such as enhanced services or the QOF.

But NICE advisors and CCG cardiology leads have claimed that GPs can do the reviews opportunistically over the coming year.

The final publication comes after it emerged the GPC had raised serious concerns over the complexity of the draft guidance – and warned CCGs would need to consider developing enhanced services to support GPs in delivering it.

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, told Pulse GPs should feel they can refer patients on if they are not able to deal with all the changes as part of annual reviews.

Dr Green said: ‘I would expect GPs as part of their normal work to consider whether [atrial fibrillation] patients not on anticoagulation should be, in the light of the new guidance. If they should be, then the choice is between anticoagulation with warfarin or one of the newer agents, and if GPs do not feel they have the expertise or resources to do this properly, they have a duty to refer to someone who can.’

He added: ‘Commissioners need to predict this activity and may want to commission a service specifically for this which is more cost-effective than a traditional out-patient referral.’

Local GP leaders told Pulse practices would not take a systematic approach to reviewing and updating patients’ medications unless the work was specifically funded.

Dr Peter Scott, a GP in Solihull and chair of the GPC in West Midlands, said: ‘It’s not going to happen unless it’s resourced and incentivised as part of a DES or LES, or through the QOF – until then I don’t think a systematic approach to this will happen.’

But Dr Matthew Fay, a GP in Shipley, Yorkshire, and member of the NICE guidelines development group, acknowledged the workload concerns and said GPs should be advised to review patients opportunistically.

Dr Fay said: ‘I think it’s perfectly acceptable [to review patients opportunistically]. A lot of these patients who are at risk in this situation we will be reviewing because of their hypertension and other comorbidities, and those patients on aspirin should have that discussed at the next presentation.’

He added: ‘I think anticoagulation is an intimidating topic for clinicians – both in primary and secondary care. I would suggest one person in each practice one clinician is involved with the management of the anticoagulated patients – whether that’s keeping a check on them during the warfarin clinic or being the person who initiates the novel oral anticoagulants.

‘If GPs feel uncomfortable with [managing anticoagulation] then they should be approaching the CCG executive to say, “we need a service to provide expert support for this”. The CCG may choose to come up with an enhanced service – but then whoever is providing the service needs to make sure they are well versed in use of the latest anticoagulants.’

The new guidance says GPs must use the CHA2DS2-VASc score to assess patients’ stroke risk and advise any patients with a score of at least one (men) or two (women) to go onto anticoagulation therapy with warfarin, or another vitamin K antagonist, or with one of the novel oral anticoagulants (NOACs) dabigatran, apixaban or rivaroxaban.

It adds that aspirin should no longer be prescribed solely for stroke prevention to patients with atrial fibrillation.

The HAS-BLED score should be used to assess patients’ risk of bleeding as part of the decision over which anticoagulant to choose.

In the only major revision to the draft guidance, aspirin is no longer to be considered even as part of dual antiplatelet therapy for patients at particularly high bleeding risk, as this combination has now also been ruled out.

NICE – management of atrial fibrillation

Related images

  • aspiirin

Readers' comments (17)

  • Hazel Drury

    So how exactly is changing someone off aspirin onto something that has been proven to work at their annual review unfunded exactly? Surely keeping patients meds up to date with current research is a core aspect of the job? I mean, it's hardly cutting edge stuff is it?
    Whilst I object to the ever increasing pointless paper pushing exercises were are commanded to do by those in ivory towers, this could actually stop one of your punters having a devastating stroke!

    Unsuitable or offensive? Report this comment

  • I think you are missing the point Hazel.

    Doing more unfunded work is being objected. I could happily do the anti-coag work but not "let's do it on the side" and if I was to do this properly, I will have to drop other unfunded work (such as organizing pointless tests requested by AED) in order to do this.

    Why? Because NICE guideline has effectively put the responsibility at my feet and this means "sorry I was to busy doing the DES to keep up my practice income and that's why I couldn't get to you till 18 month after the published date" won't cut it with the solicitor. So I'll have to proactively do this in order to act responsibly, putting other things behind.

    That's why many partners are objecting.

    Unsuitable or offensive? Report this comment

  • I don't think anyone is expected to do this any way other than opportunistically.

    When aspirin was no longer a treatment for primary prevention, I ensured all the repeat scripts for aspirin came to me, in order to check the indication. This enabled me to also stop it for AF and bring them in for discussion of anticoagulation - which at the time was part of a prescribing incentive.

    We need to be careful about objecting to offering patients the treatments in line with best practice, as this is our job. This does not need to entail recall letters - a pragmatic approach through prescribing or chronic disease reviews should be perfectly acceptable.

    Unsuitable or offensive? Report this comment

  • That would be a common sense approach (though I don't think you can go through AF Tx and explanation within 10min along side with other chronic disease review).

    However, if you have been involved with solicitor/barrister, you would know they are not interested in common sense. In fact they and their expert medical adviser often stretch the interpretation of the rules to a limit to suite their need (and they will openly admit this, it's their job). Increasingly patients are doing the same and this is reflected in our escalating indemnity fee, I always err on side of caution.

    Unsuitable or offensive? Report this comment

  • Drachula

    The first lady I put on a NOAC got vaginal bleeding. She is back on Warfarin, but she stopped that because she hates blood tests.
    Oh dear.

    Unsuitable or offensive? Report this comment

  • The list size has to go to be replaced by appointments per average practice year. Extra appointments needs to be paid for, but there is no money, so we have all the extra work of the silver age of multimorbidity to do for free. And it will forever be thus, more and more work for less.
    So, either decide to stay and put up or think of an exit strategy, because there is only extra work coming your way, you lazy, golf playing lot.

    Unsuitable or offensive? Report this comment

  • i DONT SEE WHAT IS BEING SAID HERE. wE DO MEDICATION REVIEWS ON PATIENTS WITH AF OR ANY MEDICATION YEARLY AND THIS WOULD BE DONE EVEN WITHOUT THIS RECCOMENDATION. THERE ARE MANY REASONS PATIENTS MIGHT TAKE ASPIRIN PERHAPS AGAINST ADVICE AS THEY FEAR THE OTHER ALTERNATIVES. I THINK THE CONCERN IS TAHT WE ARE NOT LEFT TO GET ON WITH OUT JOB AND ALL THE EXTRA THINGS ASKED OF US SUCH AS NAMED GP SCHEME AND COMMISIONING LEAVES US WONDERING HOW WE WILL FIND TIME TO SEE REGULAR PATIENTS AND REVIEW CHRONIC DISEASE PATIENTS WHICH IS AFTERALL A FUNDAMENTAL PART OF OUR JOB. ALL THIS WITH FEWER GPS. PERHAPS WE NEED TO SIMPLIFY THE SERVICE TO WHATS MOST IMPORTANT

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page

Have your say