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.