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):
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.
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%.
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.