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Gold, incentives and meh

This page covers the role of anticoagulation and the available options.

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 offering anticoagulation to AF patients with a CHAD2DS2-VASc score of 2 or above, taking bleeding risk into account. This may be with a vitamin K antagonist (VKA) or a non-VKA oral anticoagulant (NOAC). It should be noted, NOACs are for eligible non-valvular AF patients with one or more risk factors for stroke / systemic embolism in line with their indication.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 stroke prevention in 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 with anticoagulation therapy


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 exist in primary care practice include:5

  • 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

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Click here to view ELIQUIS (apixaban) prescribing and adverse event reporting information.

Abbreviations

AF = Atrial Fibrillation CHA2DS2-VASc = 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

References
  1. NICE. CG180. 2014. Available at: https://www.nice.org.uk/guidance/cg180. Accessed August 2019.
  2. ABPI. SAFI: One year on. 2016. Available at: http://www.abpi.org.uk/publications/safi-one-year-on/. Accessed August 2019.
  3. SSNAP Clinical audit August – November 2016. Public Report. Available at: https://www.strokeaudit.org/Documents/National/Clinical/AugNov2016/AugNov2016-PublicReport.aspx. Accessed August 2019.
  4. NHS Employers. 2018/19 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). Guidance for GMS contract 2018/19. May 2018. Available at: https://www.nhsemployers.org/-/media/Employers/Documents/Primary-care-contracts/QOF/2018-19/2018-19-QOF-guidance-for-stakeholders.pdf. Accessed August 2019.
  5. London Clinical Networks. AF Toolkit: Detect, Protect, Perfect. Available at: www.londonscn.nhs.uk/wp-content/uploads/2017/06/detect-protect-perfect-london-af-toolkit-062017.pdf. Accessed August 2019.

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Job code: 432UK1900440-01
Date of preparation: September 2019

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