atrial fibrillation - north west coast strategic clinical ...€˜working to improve the delivery of...

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


Atrial Fibrillation New and Future Treatments Study Day

Dr Tom Smith

Stroke Consultant

St Helens and Knowsley Teaching Hospitals

NHS Trust

• WELCOME

• HOUSE-KEEPING

• CMCSN – AF WORKSTREAM

• 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)

No P waves

Irregular ventricular rate

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

What causes AF?

Triggers in pulmonary veins

PV muscle sleeves contain specialised conduction tissue derived

embryologically from the neural tube and destined to have spontaneous

pacemaker activity

Potentially curative treatment:

Pulmonary Vein Isolation (PVI)

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

Comparison with other conditions C

ost p.a

. (£

mill

ion)

Stewart et al (2004) Heart;90;286-92

What symptoms does AF cause?

• Palpitations

• Awareness of an irregular/rapid heart beat

• Breathlessness

• Tiredness

• Chest pain

• Dizziness or faintness

AF impacts QOL significantly

Deleterious effects of AF

• Loss of atrial contractility

• Decreases cardiac output

• Thrombus in LA appendage

• Tachycardiomyopathy

Hazard Ratio

All cause mortality in AF patients

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

http://www.nice.org.uk/guidance/CG36/?c=91497

http://www.nice.org.uk/guidance/CG36/?c=91497

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

Elsie

• Elsie’s 5 year stroke risk is

• 1-2%

• 2-5%

• 5-10%

• 10-15%

• 15-20%

Elsie

• CHADS2 score: 5

• Annual Stroke Risk 3-4%

• 5 year stroke risk : 15-20%

Treatment options for AF

Preventing stroke in AF

• Aspirin

• Aspirin + Clopidogrel

• Warfarin

• Newer Oral Anticoagulants

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

Intrinsic pathway

Common pathway

Extrinsic pathway

Intrinsic pathway

Extrinsic pathway

Intrinsic pathway

Common pathway

Extrinsic pathway

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


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


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


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


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)

Dabigatran dosage

Management of bleeding

Warfarin Dabigatran etexilate


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


HR 0.92 0.91 0.85

p-value 0.10 0.04 <0.001

Tolerability

Dabigatran

110mg Dabigatran


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

Time in Therapeutic Range


Mean TTR 64% 55% 62.2%

Historical

Does TTR alter result?

Major Bleeding

Myocardial Infarction

Dabigatran

110mg

Dabigatran


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


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.

Summary

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?


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%)

Distribution of CHADS score

Warfarin treatment by CHADS Score

% 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%


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%


Rx Aspirin Aspirin C/I Aspirin decl

QOF Framework 2012

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 v Rhythm

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

Drugs v Ablation

Stabile et al EHJ 2006

ASSENT Trial, JS Healey et al, N Engl J Med 2012; 366:120-129

Left Atrial Appendage

Occlusion

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


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)


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


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


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


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

The GRASP-AF tool


New targets

AF6


CHADS2 score of 1, the percentage of patients who are currently

treated with anti-coagulation drug therapy or an anti-platelet therapy

AF7


CHADS2 score of greater than 1, the percentage of patients who are

currently treated with anti-coagulation drug therapy

The GRASP-AF tool

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 [email protected] with your query

Any Questions?

http://www.improvement.nhs.uk/graspaf/

mailto:[email protected]

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