What are the key changes?
The main changes for GPs are in stroke prevention:
- CHADS2 should no longer be used. GPs should now use the CHA2DS2-VASc score to assess stroke risk – and offer anticoagulation to men with a score above 0, and women with a score above 1.
- Aspirin should no longer be offered solely for stroke prevention. Only continue aspirin if a patient is on it for another reason, ie, for occlusive vascular disease and is at low risk of stroke, or does not want to start on anticoagulation, or is advised to continue on aspirin as well as anticoagulation by a cardiologist, eg as part of dual or triple antithrombotic therapy following coronary stenting
- Anticoagulation therapy can be with warfarin, another vitamin K antagonist, or one of the new oral anticoagulants – dabigatran, rivaroxaban or apixaban.
- GPs should also use the HAS-BLED score to assess bleeding risk in patients going on anticoagulation therapy, and to monitor modifiable risk factors including high blood pressure, poor INR control and harmful alcohol consumption
- For patients on warfarin, they should now have their time in therapeutic range (TTR) calculated at each visit and dosing adjusted accordingly. If poor anticoagulation control cannot be improved, discuss an alternative anticoagulant with the patient.
Why have the changes been made?
The new guidelines bring NICE up to date with the latest evidence and mean it is now more closely aligned with European Society of Cardiology guidance and the Royal College of Physicians National Clinical Guidelines for Stroke.
In particular, the CHA2DS2-VASc score is more accurate than CHADS2 at identifying those patients who are truly at low risk and do not need anticoagulation therapy.
Also it has been established for several years that aspirin is just as likely to cause bleeding as oral anticoagulants but offers far inferior protection from stroke.
What are GPs’ concerns?
Workload – GP leaders say practices are already at capacity and the additional work involved in bringing management of atrial fibrillation up to date in accordance with the guidelines is not funded through the core contract. Although some changes will be incorporated into QOF eventually, they argue the new guidelines are much more complex and should be supported through enhanced services – or there is a risk GPs will have to refer on to secondary care.
Also, CCGs in many areas are strongly discouraging GPs from using the newer oral anticoagulants. For patients who genuinely cannot cope with taking warfarin to be anticoagulated in line with the guidance, these restrictions may need to be relaxed.
What does NICE say?
For now, GPs should be encouraged to review patients on aspirin opportunistically – for example when they come in for annual reviews of their cardiovascular conditions and other comorbidities.
If they feel the process is unmanageable they should seek additional support and resources from local CCG clinical leads.
NICE has also published guidance for implementing the new recommendations – the NICE Implementation Collaborative consensus statement – with a particular focus on ensuring GPs can prescribe the newer oral anticoagulants where appropriate. The guidance states these drugs ‘should be automatically included in local formularies’.