Post on 05-May-2018
22nd March 2012
Holiday Inn, Runcorn
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Atrial Fibrillation New and Future Treatments Study Day
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Atrial Fibrillation New and Future Treatments Study Day
Dr Tom Smith
Stroke Consultant
St Helens and Knowsley Teaching Hospitals
NHS Trust
• To identify and improve the care of people
with AF in primary and secondary care
• Drivers – National Stroke Strategy,
Accelerating Stroke Improvement
Programme, Quality Outcomes Framework
• Financial – prevention saves money
• Training – co-ordination and delivery of AF
and stroke prevention training
within interested PCTs
• Formation of AF task group
• All Party Parliamentary Group for AF
• AF Study Day
An Introduction to AF and stroke
prevention
Dr Dhiraj Gupta
Consultant Cardiologist
Liverpool Heart and Chest Hospital
Honorary Senior Lecturer
Imperial College, London
What is AF?
In atrial fibrillation (AF), atrial activation
is totally chaotic
Atria are being activated 400-500
times a minute
Atria do not contract effectively
Only some of these impulses are
conducted through the AV node to the
ventricle
Ventricles are activated
rapidly (usually)
irregularly (always)
AF is a common disorder
• Prevalence of approx 1.2% in primary care in the UK
• Estimated numbers affected by AF:
• England: 600,000
• Europe: 4.5 million
• Nearly one in four people at age 55 years will go on to
develop AF (24% of men and 22% of women)3
1. NHS Improvement. June 2009
2. ACC/AHA/ESC guidelines: Fuster V et al. Circulation 2006;114:e257–354 and Eur
Heart J 2006;27:1979–2030
3. Heeringa J et al. Eur Heart J 2006;27:949–53
We may be underestimating the problem
• 30% of AF is asymptomatic1
• Many patients have paroxysmal AF
• Diagnosis requires high index of suspicion
1. Benjamin et al (1998) Circulation;98;946-52
Risk factors for AF
‘Conventional’
• Hyperthyroidism
• Structural Heart disease
• Valvular
• Ischemic
• Hypertensive
• Advanced Lung disease
Common
• Aging
• Mild Hypertension
• Obesity
• Obstructive sleep apnoea
• Diabetes
• High levels of CV fitness
PV muscle sleeves contain specialised conduction tissue derived
embryologically from the neural tube and destined to have spontaneous
pacemaker activity
Prevalence of AF increases with age
Heeringa J et al. Eur Heart J 2006;27:949–53
Women (n=4053)
Age (yrs)
55
–59
60
–64
65
–69
70
–74
75
–79
80
–84
>85
Pre
va
len
ce
(%
)
0
5
10
15
20
European age-related prevalence
Men (n=2590)
Over 85
75-84
65-74
Projected data
Office of National Statistics 1998
% o
f U
K p
opula
tion
1950 2010 2050
AF timebomb
Prevalence predicted to more than double by 2050
Miyasaki Y et al. Circulation 2006;114:119–25
0
8
10
12
16
2050
Pe
op
le w
ith
AF
in
th
e U
S (
mill
ion
s)
Year
2000 2010 2020 2030 2040
6
4
2 Projected incidence of AF assuming no further
increase in age-adjusted incidence
Projected incidence of AF assuming a
continued increase in age-adjusted incidence
as evident in 1980–2000
14
2000 cost (£m)
49.8
36.4
69.5
271.8
31.7
459.0
111.0
737.2
1307.4
1995 cost (£m)
GP consultations 29.5
Outpatient clinics 28.8
Drugs (incl. anticoag) 48.9
Hospital admissions 121.7
Post discharge OPD 15.0
Total 243.9
Nursing care 46.4
Secondary admissions 240.9
Total 531.2
Cost of AF to the NHS
What symptoms does AF cause?
• Palpitations
• Awareness of an irregular/rapid heart beat
• Breathlessness
• Tiredness
• Chest pain
• Dizziness or faintness
Deleterious effects of AF
• Loss of atrial contractility
• Decreases cardiac output
• Thrombus in LA appendage
• Tachycardiomyopathy
Mean survival from diagnosis T
ime
(Y
ea
rs)
Patients aged 55-64 at time of diagnosis
Benjamin et al (1998) Circulation;98;946-52
Time (years)
Estim
ate
d s
urv
ival (%
)
p=0.0001
Vidaillet et al (2002) Am J Med;113;365-70
AF is a slow poison…
AF and Stroke
The age adjusted incidence of stroke is
• doubled with ischaemic heart disease
• trebled with hypertension
• quadrupled in heart failure
• increased five-fold in AF
Ezekowitz et al (1995) Circulation;92;2178-82
AF and Stroke
• AF causes more severe strokes than other causes
• AF patients are twice as likely to have a fatal stroke
• 30 day mortality 25% vs 14%
• AF patients are three times as likely to be severely
dependent after a stroke
• At 12 months 30% vs 10.9%
Lin et al (1996) Stroke;27;1760-4
Estim
ate
d s
urv
ival (%
)
0 60 120 180 240 300 360
Time from stroke (days)
Lin et al (1996) Stroke;27;1760-4
p<0.001
The risk of stroke varies from patient to patient
Risk factor Relative risk of stroke
Previous stroke or TIA 2.5
History of diabetes 1.7
History of hypertension 1.6
History of heart failure 1.4
Increasing age* 1.4
•Risk can vary 20-fold between
patients2
•A number of clinical features
identified as independent risk
factors3
1. NICE clinical guideline 36.June 2006. Available at http://www.nice.org.uk/
guidance/CG36/?c=91497; accessed April 2010;
2. Gage BF et al. JAMA 2001;285:2864–70; 3. Atrial Fibrillation Investigators. Arch Intern Med 1994;154:1449-57
Estimation of stroke risk in AF: CHADS2
CHADS2 risk criteria Score
Congestive heart failure 1
Hypertension 1
Age ≥75 yrs 1
Diabetes mellitus 1
Stroke or TIA (previous history) 2
Gage BF et al. JAMA 2001;285:2864–70
CHA2DS2-VASc
• In patients with a CHADS2 score of 0–1, or
• where a more detailed stroke risk assessment is indicated
CHA2DS2-VASc risk criteria Score
Congestive heart failure/left ventricular dysfunction 1
Hypertension 1
Age ≥75 yrs 2
Diabetes mellitus 1
Stroke or TIA (previous history) 2
Vascular disease [prior MI, peripheral artery disease or aortic plaque]
1
Age 65-74 years 1
Sex category [i.e. female gender] 1
DBG1778
ESC Guidelines for the management of atrial fibrillation 2010
Case study- Elsie
• 75 year old lady
• Hypertension treated with Amlodipine
• Diabetes treated with Oral Hypoglycemics
• Otherwise fit and well
• Has a pulse check during a Flu Jab visit
• ECG: AF
Problems with warfarin
• Unpredictable Effect
• Interaction with food, alcohol and drugs
• Time in therapeutic range only 50-60%
• Bleeding
• doubles the risk of intracranial bleeding
• Slow Onset of Action
New anticoagulant drugs
Direct thrombin inhibitors
Ximelagatran (withdrawn)
Dabigatran
Activated factor Xa inhibitors
Rivaroxaban
Apixaban
Betrixaban
Edoxaban
Eribaxaban
New anticoagulant drugs
Direct thrombin inhibitors
Ximelagatran (withdrawn)
Dabigatran
Activated factor Xa inhibitors
Rivaroxaban
Apixaban
Betrixaban
Edoxaban
Eribaxaban
Conclusions
• AF is a very common disorder
• Greatly increases the risk of stroke
• Stroke risk depends upon age and common factors
• Aspirin has little/ no role in stroke prevention
• Warfarin is very effective in narrow INR range
• Newer Oral Anticoagulants likely to change landscape
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Dr Toby Nicholson
Consultant Haematologist
St Helens and Knowsley Teaching Hospitals
NHS Trust
An Overview of the New
Agents vs Warfarin
Warfarin Year Placebo Warfarin
AFASAK I 1989 4.8 2.2
SPAF I 1991 7.8 3.0
BAATAF 1990 3.0 0.6
CAFA 1991 3.7 2.5
SPINAF 1992 4.8 1.4
Overall 1989-1992 4.6 1.7
SPORTIF III 2003 2.2
SPOTIF V 2005 1.1
ACTIVE W 2006 1.4
EAFT (20) 1993 12.3 3.9
Ideal Anticoagulant • Effective.
• Safe.
• Well tolerated.
• Oral.
• Standard (once daily) dose.
• No monitoring.
• Minimal drug interaction.
• Reversible.
Warfarin • Effective.
• Safe. ?
• Well tolerated.
• Oral.
• Standard (once daily) dose.
• No monitoring.
• Minimal drug interaction.
• Reversible.
Properties Warfarin Dabigatran
etexilate
Rivaroxaban Apixaban
Action Depletory Inhibitory Inhibitory Inhibitory
Bioavailabil
ity
> 95% 6% > 80% > 50%
T (max) 72-96 hr 2 hr 2.5-4 hr 3 hr
Half-life 40 hr 14-17 hr 5-13 hr 8-15 hr
Frequency od bd od bd
Elimination CYP 2C9,
3A4, 1A2
80% renal,
20% faecal
66% renal, faecal,
CYP3A4
25% renal,
CYP3A4,
faecal
Where are they up to?
Dabigatran Rivaroxaban Apixaban
US Licensed Black box Fast-
tracked
EU Licensed Licensed Not yet
SMC Accepted Restricted N/A
NICE Option In progress N/A
Trials vs Warfarin
Dabigatran Rivaroxaban Apixaban
Trial RE-LY ROCKET AF ARISTOTLE
Design Open label Double blind Double blind
Age 71 yr 73 yr 70 yr
CHADS2 2.1 3.5 2.1
Dosing 2 doses 1 dose 1+ doses
Inclusion Criteria
RE-LY ROCKET AF ARISTOTLE
Stroke/Embolis
m
Heart Failure (40%) ½ (35%) (40%)
Age ≥ 75 years ½
HT (≥65yrs) ½
DM (≥65yrs) ½
CAD (≥65yrs)
Exclusions
RE-LY ROCKET-AF ARISTOTLE
Renal <30ml/min <30ml/min <25ml/min or creatinine >221
Antiplatelets ASA>100mg ASA>100mg ASA + clopidogrel
ASA>165mg ASA + clopidogrel
Warfarin Anything precluding warfarin treatment
AVERROES • Apixaban vs ASA when warfarin inappropriate.
• 5599 patients.
• 5mg bd vs variable dose aspirin.
• Reasons for no warfarin:
• INR unlikely to be checked as requested (43%)
• Patient refusal (37%)
• CHADS2 of 1 (21%)
• Concern about adherence to instructions (16%)
• Assessment that INR couldn’t be controlled (17%)
• Multiple reasons (51%)
AVERROES Results
Apixaban Aspirin p-value
Primary 1.6% 3.7% <0.001
Mortality 3.5% 4.4% 0.07
Major 1.4% 1.2% 0.57
NCB 5.3% 7.2% 0.003
• Terminated early.
• Mean duration of follow-up 1.1 years.
Drug Interactions
RE-LY ROCKET-AF ARISTOTLE
Not allowed Quinidine NSAIDs (2/52) Rifampicin Phenytoin
Carbamazepine Ketoconazole
Protease inhibitors
Discouraged OTC aspirin Corticosteroids
NSAIDs Heparin
Fibrinolytics
Stroke & Systemic
Embolism Dabigatran
110mg Dabigatran
150mg Rivaroxaban* Apixaban
Relative Risk
0.91 0.66 0.79 0.79
Non-inferiority
<0.001 <0.001 <0.001 <0.001
Superiority 0.34 <0.001 N/A 0.01
Haemorrhagic Stroke/ICH
Dabigatran
110mg
Dabigatran
150mg
Rivaroxaban Apixaban
CVA 0.31 0.26 0.51
ICH 0.31 0.40 0.67 0.42
<0.001 <0.001 0.02 <0.001
All Cause Mortality
Dabigatran
110mg Dabigatran
150mg Rivaroxaban Apixaban
HR for
death 0.91 0.88 0.85 0.89
p-value 0.13 0.051 0.07 0.047
Bleeding
Dabigatran 110mg
Dabigatran 150mg
Rivaroxaban Apixaban
Major 0.80 (0.003)
0.93 (0.31)
1.04 (0.58)
0.69 (<0.001)
GI 1.10 (0.43)
1.50 (<0.001)
0.89 (0.37)
All 0.78 (<0.001)
0.91 (0.002)
1.03 (0.35)
0.71 (0.001)
Management of bleeding
Warfarin Dabigatran etexilate
Rivaroxaban Apixaban
Support Local measures Stop warfarin
Vitamin K PCC
(FFP)
Support Local measures Stop dabigatran
Activated charcoal Haemodialysis
PCC rVIIa
Support Local measures
Stop rivaroxaban Activated charcoal
?Prothrombotic
Support Local measures Stop apixaban
Net Clinical Benefit
Outcome Dabigatran
110mg Dabigatran
150mg
Rivaroxaban Apixaban
HR 0.92 0.91 0.85
p-value 0.10 0.04 <0.001
Tolerability
Dabigatran
110mg Dabigatran
150mg Rivaroxaban Apixaban
Disconti
nuations 21%
(17%)
21%
(17%)
23.7%
(22.2%)
25.3%
(27.5%)
p-value <0.001 <0.001 0.001
Points of debate
• TTR - rivaroxban
• Myocardial infarction - dabigatran
• Post marketing concerns - dabigatran
Myocardial Infarction
Dabigatran
110mg
Dabigatran
150mg Rivaroxaban Apixaban
HR for
MI 1.35 1.38 0.81 0.88
p-value 0.07 0.048 0.12 0.37
Myocardial Infarction
Revised Dabigatran
110mg Dabigatran
150mg
Rivaroxaban Apixaban
HR for
MI 1.29 1.27 0.81 0.88
p-value 0.09 0.12 0.12 0.37
Explanations
• No real increase.
• Lacks protective effect of warfarin.
• No anti-Xa activity c.v. LMWH.
• CAD as entry criterion.
Post marketing
• Warnings about bleeding risk issued in:
• Australia
• Japan
• New Zealand
• FDA review in US.
• Caution about suitability of patients.
Similarities
• Convenient.
• Reduction in stroke risk (?rivaroxaban).
• Less ICH.
• Mortality reduction.
• Lack of reversal agents.
Differences • Bleeding:
• Rivaroxaban similar to warfarin.
• Dabigatran increased GI bleeds.
• Drug interactions:
• Notable with rivaroxaban.
• Dosing:
• Rivaroxaban once daily.
• Side effects:
• GI with dabigatran.
• MI risk:
• Concern about dabigatran.
CONCLUSIONS • 3 new effective, safe agents.
• Dabigatran most advanced.
• May be superseded.
• Apixaban may have clinical advantage.
• Rivaroxaban has dose schedule advantage.
• Post marketing period is vital.
• Treatment algorithms will take time.
• Individualised treatment?
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Dr Derick Todd
Consultant Cardiologist/Electrophysiologist
Liverpool Heart and Chest NHS Foundation
Trust
Other New Developments in AF
Where is their place in the era of the new
anticoagulants?
Discussion Topics
1. Anticoagulation
- GRASP data 2011
- QOF changes
- apixaban
2. Rate v rhythm management
- drugs
- ablation
3. LAA Occlusion
Extrapolated Population estimates for England
Prevalence 1.70%
Number of AF patients 934,926
Number on oral anti-coagulant 457,260
Extrapolated Population estimates for England
(NICE estimates)
Prevalence 1.70%
(1.28%)
Number of AF patients 934,926
(639,000)
Number on oral anti-coagulant 457,260 49%
(191,500 29%)
% Warfarin treatment by Age
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0-29 yrs 30-49 yrs 50-64 yrs 65-79 yrs 80+ yrs
Rx Warfarin Warfarin C/I Warfarin decl
% Warfarin treatment by Age – CHADS>1
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0-29 yrs 30-49 yrs 50-64 yrs 65-79 yrs 80+ yrs
Rx Warfarin Warfarin C/I Warfarin decl
% Aspirin treatment by Age – CHADS>1
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0-29 yrs 30-49 yrs 50-64 yrs 65-79 yrs 80+ yrs
Rx Aspirin Aspirin C/I Aspirin decl
Apixaban
• ARISTOTLE – NEJM 2011
• double-blind trial, of apixaban (at a dose of 5 mg twice daily) with warfarin
(target international normalized ratio, 2.0 to 3.0)
• 18,201 patients with atrial fibrillation and at least one additional risk factor
for stroke
• primary outcome was ischaemic or haemorrhagic stroke or systemic
embolism
• Median age 70 years / Mean CHADS score 2.1
• TTR – mean 62% and median 66%
• Discontinuation of drugs – apixaban 25.3% v warfarin 27%
• MI rates lower on apixaban
ARISTOTLE Results
• NEJM 2011
• double-blind study, we randomly assigned 5599 patients with atrial fibrillation who
were at increased risk for stroke and for whom vitamin K antagonist therapy was
unsuitable to receive apixaban (at a dose of 5 mg twice daily) or aspirin (81 to 324 mg
per day)
• primary outcome was the occurrence of stroke or systemic embolism
• Before enrollment, 40% of the patients had used a vitamin K antagonist.
• The data and safety monitoring board recommended early termination of the study
because of a clear benefit in favour of apixaban
• Mean follow-up 1.1 years
AVERROES Apixaban v Aspirin
AVERROES Results
• Mean age 70 years / CHADS score – 2
• discontinuation rates 17.9% per year for apixaban group v 20.5% per year for aspirin
Rate-control versus rhythm-control:
NICE treatment strategy decision tree
National Collaborating Centre for Chronic Conditions. NICE Clinical Guideline 36, 2006
Confirmed diagnosis of AF
Further investigations and clinical assessment including risk stratification for stroke/thromboembolism
Paroxysmal AF Persistent AF Permanent AF
OR
Rhythm-control Rate-control Remains symptomatic
Failure of rhythm-control
NICE = National Institute for Health and Clinical Excellence
NICE. 2006
p. 18
AFFIRM
Rhythm- versus Rate-control
AFFIRM=Atrial Fibrillation Follow-up Investigation of Rhythm Management
The AFFIRM Investigators. N Engl J Med 2002; 347(23): 1825–33
Cu
mu
lati
ve m
ort
ality
(%
pa
tie
nts
)
Years
All-cause death at Year 5: 23.8% versus 21.3% for rhythm versus rate control
0
30
25
20
15
10
5
Rhythm control
Rate
control
0 1 2 3 4 5
p=0.08; N=4060
AFFIRM=The Atrial Fibrillation Follow-up Investigation Of Rhythm Management; HR=hazard ratio; CI=confidence interval;
AF=atrial fibrillation Reproduced with permission from Corley SD, et al. Circulation 2004; 109: 1509–13
Insights from AFFIRM – the sinus
rhythm paradox On-treatment analysis
(n=2796; average 3.3 years follow-up)
47% reduction in mortality risk for patients in sinus
rhythm vs AF (p<0.0001)
HR (99% CI) for mortality
0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2
Rhythm-control drug use (p=0.0005 for increased
mortality risk)
Sinus rhythm
More mortality Less mortality
Drugs used:
Amiodarone
Flecainide
Sotalol
Methods:
• 4,212 patients who underwent AF ablation compared (1:4) to
• 16,848 age/gender matched controls with AF (no ablation), and
• 16,848 age/gender matched controls without AF
• followed for at least 3 years.
Results:
37,908 patients, mean age 65.0 ± 13 years,
55% paroxysmal AF / 45% persistent
25% required a 2nd procedure
TJ Bunch et al, J Cardiovasc Electrophysiol, 2011: Vol 22, pp. 839-845
PROTECT AF
• The primary efficacy event rate (a composite endpoint of stroke, cardiovascular death, and systemic embolism) of the WATCHMAN device was considered non-inferior to that of VKA (rate ratio 0.62; 95% credible interval 0.35–1.25).
• There was a higher rate of adverse safety events in the intervention group than in the control group, due mainly to periprocedural complications.
Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P.
Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of
stroke in patients with atrial fibrillation: a randomised noninferiority trial.
Lancet 2009;374:534–542.
Control, n = 244 VKA treatment (INR range 2–3)
Intervention, n = 463 percutaneous closure of the LAA (using a WATCHMAN device) and
subsequent discontinuation of warfarin
707 eligible patients randomised
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Dave Thornton
Principal Clinical Pharmacist
University Hospital Aintree
CMCSN AF Task Group
The Group
• Short lived task and finish group
• Membership comprises primary, secondary and
tertiary care representatives from across the
network
• GPs, Cardiologists, Stroke Physicians,
Haematologists, Pharmacists, Commissioners
Terms of Reference
• Review new medicines for SPAF
• Cost analysis of new agents Vs current therapy
• Develop treatment pathways for SPAF
incorporating new agents
• Initially a position statement
• Treatment pathway post NICE publication
• Promote pathway through educational events
Position Statement for NOACs
• Published and available on website
• Holding statement valid for 3 months post NICE TA
publication (dabigatran published 14.3.12)
• Advocates warfarin as the agent of choice for SPAF
• Licensed NOACs may be used in patients with genuine
intolerance to warfarin* and for short term anticoagulation in
patients listed for PVI
* Allergy, rash, side effects likely to result in
discontinuation of therapy (other than bleeding) for
example alopecia, issues with long term interacting
therapy and impossibility of monitoring arrangements
Cost Analysis • Based on local data from all CMCSN PCTs
• Looked at a number of different scenarios:
• Threshold for initiation CHADS2 > 1
• Threshold for initiation CHADS2 > 2
• All AF patients
• All new AF patients
• Patients with TTR <50%, 65% and <75%
• Patients in whom warfarin contraindicated
• A number of assumptions were used in the model
CHADS2 > 1
Patient Population Overall annual cost
(excess cost) (£)
All eligible AF patients 24 million (15m)
All new AF patients 0.47 million (0.29m)
TTR < 50% 4 million (2.1m)
TTR < 65% 9.1 million (4.9m)
TTR < 75% 14.8 million (7.9m)
Warfarin contraindicated 4.3 million
CHADS2 > 2 Patient Population Overall annual cost
(excess cost) (£)
All eligible AF patients 16.6 million (10.2m)
All new AF patients 0.33 million (0.2m)
TTR < 50% 2.8 million (1.5m)
TTR < 65% 6.3 million (3.4m)
TTR < 75% 10.2 million (5.5m)
Warfarin contraindicated 3 million
Other Work • GP Information leaflet
• Patient information leaflet
• Monitoring parameters for new agents
• Guidance on reversing new agents and dealing with bleeding
complications
• Work across North of England defining unstable INR
• Initial 3 month stabilisation phase
• TTR < 60%
• Unexplained INR > 5 more than twice in a year
• Education session today
Future Work Develop treatment pathway to inform commissioners
• NICE have now published TA 249
• Consider in nonvalvular AF with 1 or more of:
• Previous stroke or TIA or systemic embolus
• LVEF <40% or class 2 and above HF
• Age over 75
• Age over 65 plus 1 of hypertension, DM or CHD
• Dabigatran is not second line to warfarin
• Decision to switch from warfarin should be made taking INR control into
account (TTR<75%=cost effective)
‘Working to improve the delivery of services for Cardiac and Stroke patients and their families’
Ian Robson
Senior Analyst
NHS Improvement
March 2012
The GRASP – AF Tool
Overview of the programme
Aim of the programme – Reduce the number of AF-Related Strokes
Why?
Stroke is the leading complication of AF
Patients with AF have a five-fold higher stroke risk than those
without AF
AF doubles the risk of stroke when adjusted for other risk factors
Without preventive treatment, each year approximately 1 in 20
patients (5%) with AF will have a stroke
It is estimated that 15% of all strokes are caused by AF and that
12,500 strokes per year in England are directly attributable to AF
Overview of the programme
Aim of the programme – Reduce the number of AF-Related Strokes
How?
Improved detection and diagnosis
Raised awareness
Promote opportunistic detection
Ensure optimal treatment for those diagnosed with AF
Improved assessment of risk – CHADS2, CHA2DS2-VASc
Appropriate management of risk – GRASP-AF
OAC Vs. aspirin
Warfarin as ‘gold standard’ OAC
Improve anticoagulation services
CHADS2 / CHA2DS2-VASc
Risk Factor CHADS2
CHA2DS
2-VASc
Cardiac failure 1
Congestive HF / LVSD 1
Hypertension 1 1
Diabetes 1 1
Stroke or TIA 2 2
Vascular Disease 1
Age 65 - 74 1
Age >75 1 1
Female 1
CHADS2 / CHA2DS2-VASc
What’s the difference?
More patients at high risk with CHA2DS2-VASc
For Example…
80 year old, male AF patient, previous Stroke
CHADS2 = 3
CHA2DS2-VASc = 4
…67 year old, female AF patient, no other co-morbidities
CHADS2 = 0
CHA2DS2-VASc = 2
QOF changes for 2012 / 13
Old target
AF3
The percentage of patients with Atrial Fibrillation who are currently
treated with anti-coagulant drug therapy or an anti-platelet drug therapy
QOF changes for 2012 / 13
New targets
AF5
The percentage of patients with Atrial Fibrillation in whom stroke risk
has been assessed using the CHADS2 risk stratification scoring
system in the preceding 15 months
QOF changes for 2012 / 13
New targets
AF6
In those patients with Atrial Fibrillation in whom there is a record of a
CHADS2 score of 1, the percentage of patients who are currently
treated with anti-coagulation drug therapy or an anti-platelet therapy
AF7
In those patients with Atrial Fibrillation in whom there is a record of a
CHADS2 score of greater than 1, the percentage of patients who are
currently treated with anti-coagulation drug therapy
The GRASP-AF tool
What is it?
Uses free / commonly used software
A series of searches of a GPs clinical system
Looks at patients with a history of AF
Then looks at their medication and other relevant medical history
Gives a practice over view – Dashboard
Gives a patient list
QOF changes for 2012 / 13
New targets
AF6
In those patients with Atrial Fibrillation in whom there is a record of a
CHADS2 score of 1, the percentage of patients who are currently
treated with anti-coagulation drug therapy or an anti-platelet therapy
AF7
In those patients with Atrial Fibrillation in whom there is a record of a
CHADS2 score of greater than 1, the percentage of patients who are
currently treated with anti-coagulation drug therapy
The GRASP-AF tool
What changes have been made?
626 practices uploaded more than once
2.32% increase in high risk patients on anticoagulation
68 AF-related strokes prevented
35 if population standardised
5.73% increase in high risk patients coded as anticoagulation
contraindicated / declined
The GRASP-AF tool
Future projections
In all 1,746 practices that have uploaded data:
55.35% high risk patients on anticoagulation
35.90% high risk patients on antiplatelet
8.75% high risk patients on nothing
14.05% high risk patients coded as anticoagulation contraindicated /
Declined
Current treatment prevents 2,180 AF-related strokes / 1,482 deaths
The GRASP-AF tool
Future projections
If all 1,746 practices that have uploaded data:
85% high risk patients on anticoagulation
0% high risk patients on antiplatelet
15% high risk patients anticoagulation contraindicated / declined
This treatment would prevent 2,743 AF-related strokes
An increase of 564
Would prevent an extra 383 deaths
More Information
Can be found at http://www.improvement.nhs.uk/graspaf/
E-mail support:
Support for practices, networks and other organisations working with
GRASP-AF
Contact ian.robson@improvement.nhs.uk with your query
Any Questions?