Offer novel oral anticoagulants to patients with atrial fibrillation
25 Jun 2014 04:16 PM
Offering patients
anticoagulants could help prevent thousands of strokes and premature deaths
from atrial fibrillation (AF), according to
NICE.
Around 800,000 people in England
are known to be at risk of stroke from AF. Of these, half are taking
anticoagulants, and a third are currently taking aspirin.
However, two-thirds of people
admitted to a hospital with a stroke caused by AF are not taking recommended
anticoagulants. NICE estimates that with effective detection and protection
with anticoagulant drugs, 7,000 strokes and 2,000 premature deaths could be
avoided each year.
To address this, NICE
has updated its
guidelines on AF. The guideline now recommends that the CHA2DS2-VASc tool should be
used to assess stroke risk score in people with symptomatic or asymptomatic
paroxysmal, persistent or permanent AF, atrial flutter, or a continuing risk of
arrhythmia recurrence after cardioversion back to sinus
rhythm.
Patients with a
CHA2DS2-VASc score of 2 or above, taking
bleeding risk into account, should be offered anticoagulation.
Under updated recommendations,
NICE says that novel oral anticoagulants (NOACs), should be offered where
appropriate - namely apixaban, dabigatran etexilate and rivaroxaban. The NOACs
do not require the same regular level of monitoring or dose adjustments as
warfarin.
Another new recommendation
states that GPs should not offer aspirin monotherapy solely for stroke
prevention to people with AF.
Evidence shows that aspirin is
not as effective as anticoagulants at preventing stroke in people with AF who
are at increased risk of stroke, and is also not as safe in terms of causing
bleeding. Although the risks of anticoagulation also increase with age, the
evidence also shows that its benefits outweigh the risks in the vast majority
of people with AF.
Elsewhere, the guidelines say
that GPs should provide a personalised package of care to patients with AF to
help them understand their condition and make informed choices about their
treatment.
This package should be
documented and delivered, and should cover factors such as stroke awareness and
measures to prevent stoke, rate control, and who to contact if advice is
needed. It should also include up-to-date and comprehensive education and
information on the cause, effects and possible complications of AF,
anticoagulation, and practical advice on anticoagulation.
Professor Mark Baker, NICE's
Director of Clinical Practice, said: "We know that AF increases the risk
of strokes by up to five times. It's estimated that the condition causes
around 12,500 strokes each year. We also know that that around 7,000 strokes
and 2,000 premature deaths could be avoided every year through effective
detection and protection with anticoagulant drugs that prevent blood clots
forming.
"Unfortunately only half of
those who should be getting these drugs, are. This needs to change if we are to
reduce the numbers of people with AF who die needlessly or suffer life-changing
disability as a result of avoidable strokes."
Dr Matthew Fay, a GP and member
of the Guideline Development Group, explains: "With more than 10% of over
65 year olds having AF, GPs have to deal with both its identification and
management on a regular basis.
"The NICE guideline builds
on the relationship between the patient with AF and their GP, outlining how
each patient should have a clear management plan which takes into account their
personal preferences and the clinician's view of the evidence that has been
clearly laid out in the guideline."
He added: "GPs have
evidence-based tools on how to assess the patient's personal stroke risk
and their risk of bleeding and how to minimise that risk.
"The guideline incorporates
the previous positive appraisals by NICE of the newer anticoagulants apixaban,
dabigatran and rivaroxaban, positioning them clearly to enable the GP to
support patients in their choice of preventive
medication."
A consensus
statement by the NICE Implementation Collaborative (NIC) has been published
alongside the guideline which addresses some of the barriers to prescribing
NOACs.
The statement highlights that
arrangements for the use of antithrombotic therapies in AF should be reviewed
and policies developed for integration of NOACs in the local care pathway in
line with the new NICE guideline.
A patient decision aid has also been
published, which will help patients to make informed decisions about their
treatment and care.