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NICE urges GPs to adopt latest risk scores for assessing stroke risk in atrial fibrillation

GPs should routinely assess patients with atrial fibrillation using the CHA2DS2-VASc and HAS-BLED risk scores to guide decisions on anticoagulation prescribing, according to new recommendations put forward by NICE.

New draft guidance on the management of atrial fibrillation recommends offering anticoagulant therapy in patients with a CHA2DS2-VASc score of 2 or above, or in men with a CHA2DS2-VASc score of 1, providing bleeding risk has been taken into account.

GPs should use the HAS-BLED score to assess the risk of bleeding both when initiating anticoagulation therapy and monitoring patients.

They can offer antithrombotic treatment with one of the new oral anticoagulants dabigatran, apixaban and rivaroxaban or a vitamin K antagonist, but must no longer offer aspirin monotherapy solely for stroke prevention in patients with atrial fibrillation.

Aspirin should only be used as part of dual antiplatelet therapy in combination with clopidogrel, in patients for whom anticoagulation is contraindicated or not tolerated.

The guidance brings NICE more closely in line with European guidance and suggests there will now be more pressure to update the QOF – in which indicators on atrial fibrillation currently still specify use of the CHADS2 tool for stroke risk prediction and give the option of using aspirin instead of anticoagulation in patients with a CHADS2 score of 1.

Research has suggested the majority of patients with a CHADS2 score of 1 would be reclassified into a higher risk category with use of the CHA2DS2-VASc score and therefore would be in definite need of anticoagulation, while a quarter could be effectively downgraded to a lower risk that can be more confidently judged not to require treatment.

Another major change for GPs is a draft recommendation for patients on warfarin or other vitamin K antagonists to have their time in therapeutic range (TTR) to be calculated at every visit, to establish whether the dose of drug needs adjusting, or if the patient should be switched to a newer oral anticoagulant.

A NICE spokesperson said the updates on managing atrial fibrillation could be looked at this year for future inclusion in the QOF in 2015/2016.

The spokesperson said: ‘We won’t look at this guidance in terms of QOF if it is still at draft stage. If it has been published by June, when the next QOF committee meeting is being held, then they could look at any implications at that point.’

The consultation on the draft guidance closes on 26 February and the final guidance is due to be published in June.

NICE draft guidance: Management of atrial fibrillation

 

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Management of atrial fibrillation – summary of new recommendations

Assessment of stroke and bleeding risks

Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:

-    symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation

-    atrial flutter

-    a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm.

 

Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation and to highlight, correct and monitor the following modifiable risk factors:

-    uncontrolled hypertension

-    poor control of INR (‘labile INRs’)

-    concurrent medication, for example concomitant use of aspirin or an NSAID

-    harmful alcohol consumption.

 

Interventions to prevent stroke

Anticoagulation

Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, and to men with a score of 1, taking bleeding risk into account.

Assessing anticoagulation control with vitamin K antagonists

Calculate the person’s time in therapeutic range (TTR) at each visit. When calculating TTR: 

-    use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing

-    exclude measurements taken during the first 6 weeks of treatment

-    calculate TTR over a maintenance period of at least 6 months.

If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person. 

Antiplatelets

Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation.

 

Rate and rhythm control

When to offer rate or rhythm control

Assess and offer rate control as the first-line strategy to all people with atrial fibrillation. 

Left atrial ablation and a pace and ablate strategy

Left atrial ablation

If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:

-    offer left atrial catheter ablation to people with paroxysmal atrial fibrillation

-    consider left atrial surgical or catheter ablation for people with persistent atrial fibrillation

Readers' comments (6)

  • Let common sense prevail

    Increasingly complex risk score calculators, no doubt backed up by scientific evidence. But in the real world we would like answers to more practical questions, such as at what age/state of health do these calculations become irrelevant. I cannot help thinking that all my patients >90 years, with poor quality of life because of co-morbidities (dementia etc) are really not going to be helped by warfarin, and the NNT and NNH numbers would likely make interesting reading.

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  • Vinci Ho

    I think no doubt CHA2DS2-VASc is more representative as it includes other vascular co-morbidities (IHD ,PVD etc) as well as giving women one point as default.(hence the threshold to anticoagulate is 2 instead of 1 in men).
    The question of whether to anticoagulate those elderly (over 80 or 85)and quite rightly so with poor quality of life( which could be debatable from individual to individual) needs more discussions . I would probably think a 85 years old with co-morbidities and had frequent falls might tip the balance towards risk of bleeding against benefit of preventing stroke.
    This is then managing individual not science. Same argument applies to hypertension and HBA1c targets in those over 80.

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  • Newer agents.....our CCG dont want us prescribing the expensive newer agents. There is a wide variation between areas and access to these drugs is a post-code lottery.

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  • in reply to anonymous: there are positive NICE TAs for all 3 newer anticoagulants so they MUST be made available. While I don't believe they shoud routinely supplant warfarin, there is a cohort of patients with high CHA2DS2-VASc scores who are unable to take warfarin. Run GRASP-AF, find them and anticoagulate them [subject to provisos above] with a newer agent: undoubtedly a cost-effective use of NHS resources.

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  • have a look at http://www.sparctool.com/ for info around NNT and NNH, we need greater prescribing of Warfarin and/or NOACs to reduce patients stroke risk, Aspirin has very weak evidence for stroke prevention and increases the risk of ICH with little/no benefit.

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  • Samuel Lewis

    NICE has extensively researched, and consulted.

    And of course NOACs are particularly advantageous over warfarin in the labile, problematic, difficult-to-control patient. We GPs can do it easily, but would like the effort to be properly funded in the Anticoagulant Monitoring NES.

    Of course we should anticoagulate AF patients at high risk of stroke, if the benefits outweigh the harms. Are we good at judging that accurately ?

    The clinical difficulty lies in the fact that the risk-prediction tools are not terribly reliable, and not well-calibrated to this year's actual stroke risk (Des Spence - BMJ "Bad Medicine; Atrial Fibrillation").

    Note especially that stroke rates have been falling for decades for any given CHADS score. Also note that Age, Hypertension, and h/o stroke increase your HAS-BLED (harms) score just as they increase your CHADS (benefits) score. Clinical judgement and discussion is essential !

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