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Global Atrial Fibrillation (AF) Awareness Week: Three perspectives on improving outcomes for patients with AF

In this blog, three experts in cardiovascular disease (CVD) provide their perspectives on ongoing work to improve outcomes for patients with Atrial Fibrillation (AF) in England.

The NHS Long Term Plan identifies cardiovascular disease (CVD) as a clinical priority and has specific ambitions for the detection and management of the high risk conditions that affect patients with CVD. One of the high-risk conditions is atrial fibrillation (AF), which is the most common cardiac arrhythmia encountered in clinical practice and usually presents with an irregular heartbeat. It affects 1.4 million people in England, increases the risk of a stroke five times greater for people with AF and AF-related strokes are often more severe with higher mortality and greater disability.

Therefore, this Global AF Aware Week (16 – 22 November 2020), we are supporting the AF Association to raise awareness and highlight the significant progress that has been made over the last few years within primary care. Namely, both detection and management of AF have increased nationally, preventing hundreds of avoidable strokes and deaths.

Dr. Shahed Ahmad: Risk management through lifestyle interventions

The management of modifiable risk factors, including obesity, smoking, alcohol intake and physical inactivity, is an essential component in the management of AF.  A number of studies have found that patients with AF who successfully manage their risk factors demonstrate a significant reduction in their AF symptoms and were more likely to have a successful outcome following an ablation. Lifestyle interventions, even if adopted in moderation, can make a big difference.

These striking findings clearly support the NHS Long Term Plan prevention ambitions and we are now working across the organisation to identify and accelerate work that has such a profound impact on AF patients’ clinical outcomes and quality of life.

Helen Williams: Initial findings from the national Patient Optimisation Demonstrator Programme

In 2019, an AF demonstrator programme was funded by NHS England and NHS Improvement, supporting 23 CCGs to improve the rate of anticoagulation in patients with AF which is proven to reduce the risk of a stroke. The programme was based on work from Lambeth and Southwark Clinical Commissioning Groups which utilised pharmacist-led virtual clinics to identify any AF patients who were suitable for anticoagulation. Over a 12-month period, Lambeth and Southwark reviewed over 1,500 patients, which resulted in an additional 1,200 patients being anticoagulated and a 25% reduction in the rate of AF-related stroke.

Full evaluation of the impact of the larger AF demonstrator programme is yet to be reported, but the 2019/20 Quality Outcomes Framework (QOF) results for these 23 CCGs show an encouraging increase in the rate of anticoagulation of 3.45 percentage points in those with a record of a CHA2DS2-VASc score of 2 or more, compared to 1.38 percentage points for all other CCGs across England. Taking into account the growth in the atrial fibrillation anticoagulation rates seen in other CCGs, the programme may have resulted in an additional 2,300 people with AF across these 23 CCGs bring prescribed anticoagulation which could prevent up to 90 AF-related strokes. Note: To account for CCG changes over time, the 23 CCGs have been taken to consist of the same GP practices as 2017/18 (when the programme started).

In addition, pharmacist-patient conversations about anticoagulation were also supported by shared decision-making training which has been shown can improve patient clinical outcomes, patient experience, adherence to treatment and reduce unwarranted variation in care. See an NHS England and Improvement Instagram post to read a testimonial from a trained pharmacist discussing the importance of shared decision making.

Ahmet Fuat: Strategies to detect, protect and perfect AF management in Darlington

In Darlington CCG, and now PCN, we cover 109,000 patients over 11 GP practices. We believe it is vital our primary health care teams employ strategies to detect AF, protect patients against AF-related strokes and perfect AF management for our patients (detect, protect and perfect):

Detect

We use an embedded platform, OBEROI SPAF & Case Finding Service, to search our systems to identify eligible patients and send monthly reminders to practice CVD leads. This technology has seen us detect an extra 113 patients over 8 months (October 2019 to May 2020) across the PCN, increasing prevalence from 2.24% to 2.34% and an increase from 80% to 84% of estimated prevalence (the national ambition is 85%).

In addition, GP practices have pulse prompts for all patients over 65, and those under 65 with co-morbidities that increase the risk of AF e.g. hypertension, diabetes, heart failure, and podiatry clinics perform foot pulse checks for patients with diabetes and other co-morbidities and refer those with an irregular pulse to GPs.

Protect

Most international guidelines now recommend direct oral anticoagulants (DOACs) in preference to warfarin for anticoagulation in non-valvular AF. A recent study highlighted the higher risk of all-cause mortality in AF with non-recommended doses of DOACs.

Therefore, we support colleagues to offer optimal anticoagulation medication to all those who would benefit and our anticoagulation rates (90.9%) surpass the national ambition of 90%.

Perfect

We also support colleagues to review patients’ medications and, over the last 9 months, where possible, we have been switching patients from warfarin to DOACs.

Overall, we are confident that these strategies are working as Darlington CCG has the lowest AF-related stroke rates of any CCG in North East and North Cumbria.

This blog has highlighted work and celebrated the significant improvements in management for patients with AF at both regional and local levels. The current pandemic is a threat to progress in this area; however, it is imperative primary care colleagues stay focussed on AF and other high-risk conditions to continue to prevent strokes and deaths.

Dr Shahed Ahmad

National Clinical Director for Cardiovascular Disease Prevention at NHS England and NHS Improvement.

Dr Shahed Ahmad is an NHS England/ Improvement Medical Director in the South East Region where he is the Responsible Officer for over 3000 GPs. Shahed was educated at Corpus Christi College, Cambridge and University College and Middlesex School of Medicine. Shahed did his MSc in Public Health at the London School of Hygiene and Tropical Medicine and his leadership training at the London Business School. Before working for NHS England, Shahed was a Director of Public Health and led on cardiovascular risk reduction in a number of boroughs. Since joining NHS England, Shahed developed the NHS@2030 programme for GPs in South Central (a number of whom are now Clinical Directors of PCNs) and developed the Hampshire Thames Valley Leadership Forum.

Ahmet Fuat

GP, GPSI in Cardiology Darlington and Honorary Professor of Primary Care Cardiology at Durham University.

Professor Ahmet Fuat has been a GP in Darlington, Co.Durham for 33 years.

He has been a GPSI Cardiology for 20 years having undertaken a Postgraduate Diploma in Cardiology at Bradford University graduating with distinction. He started the first one stop diagnostic and integrated heart failure clinic in the UK in 17 years ago with local colleagues.

His PhD by research in heart failure diagnosis and management including work on natriuretic peptides generated several publications that have informed guidelines and led to the award of an Honorary Professorial Chair at Durham University.

He holds various roles in CVD and research including the Past President of the new Primary Care Cardiovascular Society (PCCS) which he was instrumental in reforming, CVD Clinical Adviser to the RCGP, CVD and Research Leads for Darlington Primary Care Network (PCN) and Federation, Associate Lead for Industry Research at North East and North Cumbria NIHR CRN. He has recently been elected onto the newly formed Darlington PCN Governing body as a GP member, CVD, Research Leads and Chair.

He has a passion for medical education and remains an active lecturer, tutor and researcher. He is on the editorial boards of the British Journal of Cardiology and Primary Care Cardiovascular Journals and a peer reviewer for most high impact Cardiovascular journals and research bodies. His work in community cardiology has been recognised with Fellowships from the RCGP, RCP London and RCP Edinburgh.

National Specialty Adviser for Cardiovascular Disease Prevention at NHS England and NHS Improvement.

Helen Williams has worked as a CVD specialist pharmacist for the past 25 years in hospital, community and primary care settings. She has spearheaded a wide range of activities across South London and beyond to improve the care of patients with or at risk of cardiovascular disease (CVD). She leads on the development and implementation of consensus evidence-based guidance for use across South London’s 12 CCGs and 7 acute trusts, covering a population of 3.6million and supporting local practitioners through education and training, guideline implementation, clinical audit, service development and provision of virtual or face to face clinics. For the past three years she has provided clinical advice to inform the delivery of local and national AF AHSN programmes to optimise the detection and management of AF with the aim of reducing AF-related stroke. She developed the pharmacist-led virtual clinic model to optimise uptake of anticoagulation in AF in Lambeth and Southwark CCGs, which is now being spreads nationally through the NHSE AF demonstrator programme. Helen has supported the commissioning and delivery of CVD new models of care to address the CVD ABCs, – AF, blood pressure and cholesterol.