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About atrial fibrillation
Atrial fibrillation (AF) has been diagnosed in about 1.3 million patients and many more remain undiagnosed.
AF increases the risk of stroke up to five times and is significantly associated with death and hospitalisation, as well as being strongly linked to heart failure and vascular dementia.
Early detection of atrial fibrillation is critically important, with an increased frequency of pulse checks in those >65 years shown to simply identify patients at risk.
There have been important developments in the use of anticoagulant therapy.
Evidence based tools for risk assessment – particularly CHA2DS2-VASc Score is recommended to maximise the risk of bleeding in non-valvular AF.
New therapeutics – The direct oral anticoagulants (DOACs) – have offered more convenient and easier to use therapy versus the previous standard of Warfarin. Direct factor Xa inhibitors (Adixaban, Rivaroxoban and Endoxaban) and the direct thrombin inhibitor (Dabigatran) have become widely used in primary care.
Therapeutic interventions in atrial fibrillation primarily aim at reducing symptoms and improving or maintaining patients’ health-related quality of life (HRQoL). As most studies in this area have focused on randomised trial populations with highly symptomatic patients, this large observational study aims to assess HRQoL in a typical UK general practice setting.
Managing stroke risk in people with atrial fibrillation (AF) is critical. The introduction of the CHAVASc score has lowered the threshold for consideration of anticoagulation to prevent stroke in AF. This means potentially extra work for clinicians in assessing AF patients, and an extra cost to the NHS from more medication and monitoring. This study aims to quantify the increase in the numbers of people requiring anticoagulation with the newer risk assessment score. Method: The GRASP-AF tool was used to quantify the number of people categorised as high risk, using the CHAVASc score compared with the standard CHADS score. Population: An inner-city population from nine general practices within a single Clinical Commissioning Group (CCG), covering a population of 42,274 patients. Results: A total of 395 patients were found to have AF. In this study, 64% were categorised as high risk using CHADS compared with 87% on CHAVASc. This represents an increase of 35% in the numbers of people classed at high risk of stroke and needing to be considered for anticoagulation. Conclusion: There are significant extra costs to implementing the CHAVASc score, both in drug costs and extra work for primary care, which need to be managed within the local health system. The greatest benefit will be at an individual level. Some people who would have had a stroke will be spared that experience. Who those individuals are, we will never know.
Patient satisfaction with treatment is a key component of the successful management of chronic conditions such as atrial fibrillation (AF). In the EUropean Patient Survey in Atrial Fibrillation (EUPS-AF) survey, UK patients reported the highest rates of satisfaction with their healthcare system and quality of care. However, only about half of UK patients reported receiving regular anticoagulation testing and about one third had never or rarely had a medication review. This survey provides important insights into the current provision of care that should be taken into account when designing and commissioning patient-centred AF services.
Warfarin is highly effective in preventing strokes in people with atrial fibrillation (AF), but has its limitations. Only half of patients who could benefit actually receive warfarin, resulting in an estimated 7000 avoidable strokes each year.
Through the support of NHS Improvement, Guidance on Risk Assessment for Stroke Prevention in Atrial Fibrillation (GRASP-AF) has been rolled out nationally. Nearly 2,000 practices have adopted the GRASP concept, representing an overall population of 13 million.
The study found a significant prevalence of sub-clinical atrial fibrillation (AF) within the community. AF confers a five-fold risk of stroke, and the risk of death is doubled in AF-related stroke.
The management of AF is one of the most rapidly evolving areas of primary care today. How will these changes alter management in the coming months?
Dr Frances Akinwunmi
Consultant Pharmacist (Anticoagulation), Imperial College Healthcare NHS Trust
Professor David Fitzmaurice
Professor of Primary Care, University of Birmingham
Dr Matthew Fay
GP and National Clinical Lead for Atrial Fibrillation, Westcliffe Medical Centre, Shipley
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Its incidence rises with age: in the over-65s the prevalence is 4% but this rises to 8.8% in the over-80s. The prevalence of AF is on the rise due, in part, to an ageing general population and to increased longevity resulting from improved medical care. AF is clinically important because it contributes to the incidence of heart failure, stroke and overall cardiovascular mortality. In addition, when strokes occur in association with AF, patients suffer substantial mortality, disability and longer hospital stays compared to stroke patients without AF, leading to an increased financial and resource burden on the NHS.
In the last few years we have witnessed a number of advances in the management of atrial fibrillation (AF). While these have created valuable opportunities to improve patient outcomes, we need to ensure physicians have the right support to deliver the most appropriate care. The AF AWARE (Atrial Fibrillation AWareness And Risk Education) campaign, working with a panel of AF experts, has developed the Atrial Fibrillation in Primary care (AFIP) tool – a ‘go to’ resource for primary care physicians, to help with the identification and management of AF, in line with the latest published guidelines. This article provides some background to the need for such a tool, and an outline of its content.
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