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GPs go forth

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The final publication comes after it emerged the GPC had raised serious concerns over the complexity of the draft guidance – and warned CCGs would need to consider developing enhanced services to support GPs in delivering it.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

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Readers' comments (17)

  • Just Your Average Joe

    Get ready to blow prescribing budgets out of the water.

    As the only easy unfunded easy to do the switch is to swap to a Novel agent.

    As the time and hassle and multiple appointments needed to swap to warfarin in the community means unless GPs will have to do it for free and there are just not enough hours in the day for this work and continue to monitor so many new patients.

    swap straight to a NOAC and if any problems - deal with those on a case by case basis only cost effective way to go.

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  • GPs are ' to be tasked' - ealier it was 'GPs must' or 'GPs warned' or 'GPs told to...' by NICE.
    Not very NICE considering that the credibility of GPs and healthcare professionals is put to test when the public hears that for decades we have been treating them unnecessarily with aspirin and causing bleeding and ulcers in some by giving them aspirin.
    Now aspirin is hindering the business of 'new anticoagulants' with a decent lobby in the right places. So who cares about credibility - GPs can take another bash and will still survive.Or maybe, NICE should step back and re-consider what they wish for because you can't keep pushing drugs that will ruin the economy.

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  • More than happy to, if NICE comes to my surgery and reviews those patients for me, changes the tablets, explains to my patients the risks of NOACs and deals with the fallout from say, any GI bleeds or cerebral bleeds.

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  • Vinci Ho

    (1) while I have no doubt this is the way forward as far as preventing stroke in these patients are concerned, the problem is still 'money'
    (2)Accordingly , the budget gap for NHS is still around 2 billions even with further vigorous exercise of the fallible efficiency saving . It is no way to see more prescribing of NOAC a main trend.
    (3) the monitoring of warfarin is costly as well . My concern is we end up with a second rate , unsafe warfarin monitoring service in the community(Forget secondary care on this issue )
    (4) CHA2DS2-VASc should have been used in the current QOF instead of the old version but HAS-BLED can be time consuming , and needs some training to develop the expertise to make a decision for your patients. It will help if the practice is allocated a medicine management team from CCG.
    (5) cough up more funding for NHS, Treasurer!!

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  • I find it odd that this is news to anyone. We have been having these discussions with patients for the last 2 years.

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  • GPs follow QoF not guidelines which explains why the practice tends to lag behind current expert opinion.So unless you update QoF you won't make much headway.

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

    Seriously? Why don't they try doing CHADS2-VASC and HAS-BLED as well as deciding Tx referring for warfarin monitor as well as consulting the patient for their original reason for appointment in TEN MINUTE.

    I would urge these doctors to stop climing the Ivory tower so high - it gives them false sense of grandur when they are so high up and starves their brain of oxygen which leads to irrational comments like the one above.

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  • @at above

    ..aah but we're supposed to offer them "whatever it takes" minute appointments now aren't we

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  • Hazel Drury

    Hmmm... not sure I understand objections of anyone on this. As Dr. Nabi says above, we've been doing this for years? Are folk now moaning that they have to put their patients onto the latest research based evidence at their annual review?? WTF?

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  • No, we are not complaining about the clinical appropriateness - we are complaining we are being asked shoulder yet more unfunded work.

    You'll have to remember we are already carrying a lot more work this year - unplanned admission DES is already proving to be a lot more cumbersome then QoF it replaced, blamed GP scheme is costing a lot of money and time, secondary care is burdening us with more work, increased access demands esp with the cancer campaign etc etc. As we are already struggling to cope with current demand where do you suppose we fit this in?

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