GPs should routinely assess patients with atrial fibrillation using the CHA2DS2-VASc and HAS-BLED risk scores to guide decisions on anticoagulation prescribing, according to new recommendations put forward by NICE.
New draft guidance on the management of atrial fibrillation recommends offering anticoagulant therapy in patients with a CHA2DS2-VASc score of 2 or above, or in men with a CHA2DS2-VASc score of 1, providing bleeding risk has been taken into account.
GPs should use the HAS-BLED score to assess the risk of bleeding both when initiating anticoagulation therapy and monitoring patients.
They can offer antithrombotic treatment with one of the new oral anticoagulants dabigatran, apixaban and rivaroxaban or a vitamin K antagonist, but must no longer offer aspirin monotherapy solely for stroke prevention in patients with atrial fibrillation.
Aspirin should only be used as part of dual antiplatelet therapy in combination with clopidogrel, in patients for whom anticoagulation is contraindicated or not tolerated.
The guidance brings NICE more closely in line with European guidance and suggests there will now be more pressure to update the QOF – in which indicators on atrial fibrillation currently still specify use of the CHADS2 tool for stroke risk prediction and give the option of using aspirin instead of anticoagulation in patients with a CHADS2 score of 1.
Research has suggested the majority of patients with a CHADS2 score of 1 would be reclassified into a higher risk category with use of the CHA2DS2-VASc score and therefore would be in definite need of anticoagulation, while a quarter could be effectively downgraded to a lower risk that can be more confidently judged not to require treatment.
Another major change for GPs is a draft recommendation for patients on warfarin or other vitamin K antagonists to have their time in therapeutic range (TTR) to be calculated at every visit, to establish whether the dose of drug needs adjusting, or if the patient should be switched to a newer oral anticoagulant.
A NICE spokesperson said the updates on managing atrial fibrillation could be looked at this year for future inclusion in the QOF in 2015/2016.
The spokesperson said: ‘We won’t look at this guidance in terms of QOF if it is still at draft stage. If it has been published by June, when the next QOF committee meeting is being held, then they could look at any implications at that point.’
The consultation on the draft guidance closes on 26 February and the final guidance is due to be published in June.
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Management of atrial fibrillation – summary of new recommendations
Assessment of stroke and bleeding risks
Use the CHA2DS2-VASc stroke risk score to assess stroke risk in people with any of the following:
– symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation
– atrial flutter
– a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm.
Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation and to highlight, correct and monitor the following modifiable risk factors:
– uncontrolled hypertension
– poor control of INR (‘labile INRs’)
– concurrent medication, for example concomitant use of aspirin or an NSAID
– harmful alcohol consumption.
Interventions to prevent stroke
Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, and to men with a score of 1, taking bleeding risk into account.
Assessing anticoagulation control with vitamin K antagonists
Calculate the person’s time in therapeutic range (TTR) at each visit. When calculating TTR:
– use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing
– exclude measurements taken during the first 6 weeks of treatment
– calculate TTR over a maintenance period of at least 6 months.
If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative stroke prevention strategies and discuss these with the person.
Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation.
Rate and rhythm control
When to offer rate or rhythm control
Assess and offer rate control as the first-line strategy to all people with atrial fibrillation.
Left atrial ablation and a pace and ablate strategy
Left atrial ablation
If drug treatment has failed to control symptoms of atrial fibrillation or is unsuitable:
– offer left atrial catheter ablation to people with paroxysmal atrial fibrillation
– consider left atrial surgical or catheter ablation for people with persistent atrial fibrillation