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GPs will stop initiating atrial fibrillation treatment under proposed NICE guidelines, BMA warns

Exclusive GPs will cease initiating treatment to prevent strokes in patients with atrial fibrillation if NICE pushes through complicated guidelines that require an exhaustive discussion of the risks and benefits of all new anticoagulant treatments, the BMA has said.

In its official response to the ongoing NICE consultation, the BMA warned that the rewrite of best practice guidance for managing AF is ‘considerably more complex’ than current guidelines and GPs will be more likely to refer patients to secondary care as a result.

GP experts said there could be ‘terrible consequences’ if the guidelines, which will be finalised next month, were pushed through as practices did not have the time or the expertise to carry out what was expected in the draft guideline.

The BMA also warned that the new guidelines could drastically increase the prescription of newer alternatives to warfarin, with major cost implications for CCGs.

Under the proposed new guidelines, NICE wants clinicians to have in-depth conversations about the all relative risks and benefits of warfarin and the newer anticoagulants - apixaban, dabigatran and rivaroxaban - when patients are prescribed a treatment to preventing strokes and systemic embolism.

It also called for GPs to routinely assess patients with atrial fibrillation using the CHA2DS2-VASc and HAS-BLED risk scores to guide decisions on anticoagulation prescribing.

The draft guidelines say that the decision about whether use a particular treatment ‘should be made after an informed discussion between the clinician and the person about the risks and benefits’ of the treatment compared with all other options.

The BMA welcomed new advice from NICE that aspirin should no longer be prescribed for patients considered at risk of stroke, but added: ‘This is an extensive re-write of existing recommendations and it is considerably more complex. We suspect that most GPs will no longer be comfortable with managing AF in primary care.’

It went on to day: ‘Most patients will be referred in order to gain specialist advice on the desirability of the modern treatments.’

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, told Pulse that the BMA supported the principles behind the guidance, but warned that only a GP with a special interest in cardiology will have the expertise to counsel patients ‘to the required standard’.

He said: ‘The difficulty is that several anticoagulants have come on to the market in a relatively short period of time. We are pretty good at treating with warfarin, but there is less knowledge about the others.’

‘The NICE guidance suggests a great deal more discussion with patients, simply because there are more options. Many GPs will be concerned about this complexity, and will refer patients on to secondary care for these discussions.’

Dr Christine A’Court, heart failure lead for NHS Oxfordshire CCG and a cardiology GPSI, said there could be ‘terrible consequences’ if GPs increased referrals to secondary care.

She said: ‘While I support the idea of a good discussion with patients about managing AF this guidance will impose a huge workload on GPs at a time when they are already under considerable pressures.

‘The knowledge required for an in-depth discussion is considerable. In time GPs could rise to the challenge, but in the short and medium term there will be terrible consequences in terms of cost if it leads to more secondary care referrals.’

The BMA also said that the guidance could lead to increasing numbers of patients choosing anticoagulant treatments were are more expensive than warfarin, which will also have implications for the drug budgets of CCGs.

A Pulse investigation last year found that although GPs were increasingly prescribing the newer anticoagulant alternatives to warfarin for the prevention of stroke, their uptake had been slower than expected due to cost concerns.

Dr Green stressed that the BMA supports many of the principles in the NICE draft guidance, such as the recommendation that aspirin monotherapy should not be used to prevent strokes among AF patients.

Dr Green said: ‘Aspirin treatment is no good at all, and if you can get patients on anticoagulation there will be an enormous step forward for their health. We should be anticoagulating patients unless there’s a definite reason not to.’

The consultation closed in February and NICE is expected to produce a final version next month.

A NICE spokesperson could not say whether NICE would make any changes to the draft guidance as a result of GPs’ concerns.

Please note: This article was amended at 11:39 to make clear the BMA’s concerns relate to the intiation of stroke prevention treatment for atrial fibrillation, rather than the management of AF itself.

Related images

  • ecg atrial fibrillation  PPL - online

Readers' comments (13)

  • Excellent. A long 10-20minute discussion with the patient about relative risks, the risks of bleeding vs emboli and a comparison of all of the agents available. This will be followed by: "I don't understand, doctor. Which one should I take?". And then they can be put on warfarin as per usual.

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  • I think there should be a gradual shift of non-contracted work back to secondary care. And this seems like a good place to start.

    Honestly if I was in need of treatment like this I would want the opinion of a consultant.

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  • This is a pity. It's not a difficult consultation, didn't require much skill our experience and as the decision making process is clear, it's something non specialist can do with the right knowledge.

    Having said that, we'll need to be properly funded as even now, full discussion including life style risk factor will take at least 15-20 min. So unless I'll get funded for it, I'll have to refer patients to secondary care.

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  • since all GPs are "crap" according to The Daily Mail, we should all accept society's verdict and send ALL the patients to the clever hospital doctors. Overnight secondary care would collapse!! NICE is an organisation run by academic professors who have never seen a real patient and spend all day writing huge voluminous papers expanding everyday decisions into mammoth MDT concepts. This medical bearucracy will strangle fragile General Practice into asystole.

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  • Vinci Ho

    It is all about time
    Academics can forget about GPs because it is NOT SAFE to accomplish these tasks in 10 minutes
    Need more GPs with special interest but even them will need more time

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  • Brilliant I will refer them all, now while we're on that subject can i refer all my heart failure, diabetic, asthma, copd, cardiovascular patients too? Well now that there is no QOF and we are all considered crap then perhaps consultants can just get on with it and see all the patients they used to see? Oh hang on is that too expensive? What a shame.....

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  • another guideline that we are meant become experts in and consult accordingly and have responsibility for

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  • This is a bit odd as explaining decisions based on a complex balance of risks and benefits isn't new. In fact all the evidence suggests that Gp's tend to do it rather well and frequently I see patients to help them work through the senario of should I have surgery/ chemo etc. as the consultant has the indepth knowledge but struggles to convey it in a way that allows the patient to make a decision. There will always be some people who prefer or need to see a specialist but this is catered for under the current system. The people with the most difficult balancing or risks and benefits will be the frail elderly with multiple comorbidities who often prefer to see a doctor they know and trust.

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  • Russell Thorpe

    When this guidline is finalised and published the first thing I will look at will be the register of declared interests of the members of the guidline committee.

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  • Samuel Lewis

    What ?? The BMA opposes progress ?

    nothing new there then !

    After solid RCT evidence, NICE declared 2 years ago that non-valvular AF patients should be offered the option of a NOAC. It would be particularly cost-effective in those with labile INRs and frequent testing.

    How did NHS Wales respond ? by dragging its feet and closing ranks.

    Is counselling, prescribing, and monitoring of Warfarin difficult ? Yes. Barely worth the Anticoagulant Monitoring NES fee. Is it dangerous ? Yes - just recall the almost weekly close-shaves you have with it.

    Is NOAC easier, safer, and less trouble ? You bet ! Look at the RCT data. 25% of our anticoagulated patients are now on Rivaroxaban, and rising.

    Wake up and smell the coffee !

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