GPs are to be tasked with reviewing all their patients with atrial fibrillation who are taking aspirin, under final NICE guidance published today that recommends anticoagulant therapy as the only option for stroke prevention in these patients.
The new guidance means GPs will need to start advising patients with atrial fibrillation who are on aspirin to stop taking it, and encourage them to take warfarin or one of the newer oral anticoagulants.
NICE said just over a fifth of the UK population with atrial fibrillation – around 200,000 patients – are currently on aspirin, many of whom should be able to be switched onto anticoagulation therapy of some sort.
GP leaders have warned that practices do not have the capacity to proactively call in patients, and suggested that changing management of this number of patients could only be achieved through incentive schemes such as enhanced services or the QOF.
But NICE advisors and CCG cardiology leads have claimed that GPs can do the reviews opportunistically over the coming year.
The final publication comes after it emerged the GPC had raised serious concerns over the complexity of the draft guidance – and warned CCGs would need to consider developing enhanced services to support GPs in delivering it.
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, told Pulse GPs should feel they can refer patients on if they are not able to deal with all the changes as part of annual reviews.
Dr Green said: ‘I would expect GPs as part of their normal work to consider whether [atrial fibrillation] patients not on anticoagulation should be, in the light of the new guidance. If they should be, then the choice is between anticoagulation with warfarin or one of the newer agents, and if GPs do not feel they have the expertise or resources to do this properly, they have a duty to refer to someone who can.’
He added: ‘Commissioners need to predict this activity and may want to commission a service specifically for this which is more cost-effective than a traditional out-patient referral.’
Local GP leaders told Pulse practices would not take a systematic approach to reviewing and updating patients’ medications unless the work was specifically funded.
Dr Peter Scott, a GP in Solihull and chair of the GPC in West Midlands, said: ‘It’s not going to happen unless it’s resourced and incentivised as part of a DES or LES, or through the QOF – until then I don’t think a systematic approach to this will happen.’
But Dr Matthew Fay, a GP in Shipley, Yorkshire, and member of the NICE guidelines development group, acknowledged the workload concerns and said GPs should be advised to review patients opportunistically.
Dr Fay said: ‘I think it’s perfectly acceptable [to review patients opportunistically]. A lot of these patients who are at risk in this situation we will be reviewing because of their hypertension and other comorbidities, and those patients on aspirin should have that discussed at the next presentation.’
He added: ‘I think anticoagulation is an intimidating topic for clinicians – both in primary and secondary care. I would suggest one person in each practice one clinician is involved with the management of the anticoagulated patients – whether that’s keeping a check on them during the warfarin clinic or being the person who initiates the novel oral anticoagulants.
‘If GPs feel uncomfortable with [managing anticoagulation] then they should be approaching the CCG executive to say, “we need a service to provide expert support for this”. The CCG may choose to come up with an enhanced service – but then whoever is providing the service needs to make sure they are well versed in use of the latest anticoagulants.’
The new guidance says GPs must use the CHA2DS2-VASc score to assess patients’ stroke risk and advise any patients with a score of at least one (men) or two (women) to go onto anticoagulation therapy with warfarin, or another vitamin K antagonist, or with one of the novel oral anticoagulants (NOACs) dabigatran, apixaban or rivaroxaban.
It adds that aspirin should no longer be prescribed solely for stroke prevention to patients with atrial fibrillation.
The HAS-BLED score should be used to assess patients’ risk of bleeding as part of the decision over which anticoagulant to choose.
In the only major revision to the draft guidance, aspirin is no longer to be considered even as part of dual antiplatelet therapy for patients at particularly high bleeding risk, as this combination has now also been ruled out.