Current clinical practice challenges
If left untreated, AF is a significant risk factor for stroke and other morbidities.1 Yet the realities of everyday clinical practice mean that guideline recommendations are not always adhered to.
NICE Clinical Guideline CG180 recommends that anticoagulation with a vitamin K antagonist (VKA) or with a non-VKA oral anticoagulant (NOAC) should be offered to non-valvular AF (NVAF) patients with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account.1
However, data showed in 2015 that only half of AF patients admitted for stroke were taking anticoagulation.2 Furthermore, an audit of hospital admissions for stroke revealed that 22.5% were receiving antiplatelet medication prior to admission, and that 20% were taking only antiplatelet drugs, which are considered ineffective for patients with AF, contradicting recommendations.3 Such figures highlight the opportunity to improve AF patient care.
NICE Quality and Outcomes Framework (QOF) indicators in AF focus on addressing two key gaps in AF clinical practice:4
- the number of patients who are unassessed for stroke risk
- the number of eligible patients who remain untreated
Our patients need us to 'Protect'
The Protect domain of Detect, Protect, Perfect aims to address current challenges in ensuring all eligible AF patients receive appropriate anticoagulation. Opportunities for improvement that in primary care practice include:6
- Assessing all AF patients using the CHA2DS2-VASc score to assess stroke risk
- Using the HAS-BLED score to assess the risk of bleeding in those who are starting or have started anticoagulation
- Protecting patients who are most at risk of stroke (those with a CHA2DS2-VASc ≥2) by ensuring that all eligible patients have access to treatment with an anticoagulant
- Initiating anticoagulation in community settings
- Discontinuing use of antiplatelet therapy solely for stroke prevention
- Correct heart rhythm where necessary
- Ensuring mechanisms are in place to monitor and support people on anticoagulation
Click here to view ELIQUIS prescribing and adverse event reporting information.
AF = Atrial Fibrillation CHA2DS2VASc = Congestive Heart Failure, Hypertension, Age (double if ≥75), Diabetes, Stroke or TIA (double), Vascular disease, Sex HAS-BLED = Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol NOAC = Non-VKA Oral Anticoagulant QOF = Quality and Outcomes Framework VKA = Vitamin K Antagonist
- NICE. CG180. 2014. Accessed May 2019. Available at: https://www.nice.org.uk/guidance/cg180.
- ABPI. SAFI: One year on. 2016. Accessed May 2019. Available at: http://www.abpi.org.uk/publications/safi-one-year-on/
- SSNAP Clinical audit August – November 2016. Public Report. Accessed May 2019. Available at: https://www.strokeaudit.org/Documents/National/Clinical/AugNov2016/AugNov2016-PublicReport.aspx.
- NHS Employers. 2018/19 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). Guidance for GMS contract 2018/19. May 2018. Accessed May 2019. Available at https://www.nhsemployers.org/-/media/Employers/Documents/Primary-care-contracts/QOF/2018-19/2018-19-QOF-guidance-for-stakeholders.pdf.
- Imperial College Health Partners. AF Budget Impact Model. Accessed May 2019. Available at: https://imperialcollegehealthpartners.com/af-budget-impact-model/.
- London Clinical Networks. AF Toolkit: Detect, Protect, Perfect. Accessed May 2019. Available at: www.londonscn.nhs.uk/wp-content/uploads/2017/06/detect-protect-perfect-london-af-toolkit-062017.pdf
Job code: 432UK1900440-01
Date of Prep: May 2019