AF A ™ www.afa.org.uk IN PURSUIT OF EXCELLENCE IN THE PREVENTION OF AF-RELATED STROKE Initiative supported by an unrestricted educational grant from Daiichi Sankyo UK Ltd. Report content developed from a multi-stakeholder meeting in 2015, hosted by the AF Association and chaired by Professor Martin Cowie, Imperial College London, and in follow-up with experts after the meeting. Meeting attendees and report contributors include: Meeting Chair: Professor Martin Cowie, Professor of Cardiology, Imperial College London and Honorary Consultant Cardiologist at the Royal Brompton and Harefield NHS Foundation Trust. Member of AF Association Medical Advisory Committee; Trudie Lobban MBE, FRCP Edin, Founder & CEO, AF Association; Angela Griffiths, Arrhythmia Advanced Nurse Practitioner, John Radcliffe Hospital, Oxford. Member of AF Association Medical Advisory Committee; Dr Chris Arden, General Practitioner, Park Surgery, Chandlers Ford, Hampshire; Dr Dhiraj Gupta, Consultant Cardiologist and Electrophysiologist, Liverpool Heart and Chest Hospital. Member of AF Association Medical Advisory Committee; Jane Macdonald, Director of Nursing and Improvement at Greater Manchester Academic Health Science Network; Melanie Green, Head of Medicines Management, NHS South Gloucestershire CCG; Sotiris Antoniou, Consultant Pharmacist, Cardiovascular Medicine, Barts Health NHS Trust. Member of AF Association Medical Advisory Committee. 02 – In Pursuit of Excellence FOREWORD With an ageing population, atrial fibrillation (AF), a common Over the following pages you will find an overview of the cardiac rhythm disorder, is increasing1,2 and will only continue impact of AF-related stroke, and a look at the current situation to do so. As one of the biggest independent risk factors for around uptake of NOACs in England, including variance stroke,3 as well as the fact that AF-related strokes are more across the country due to local barriers and challenges. severe,2,4 inappropriate management of this condition can Importantly, you will also find good examples of best have devastating consequences. While we have come a practice where individuals, practices, groups and others are long way in awareness, detection and management of this implementing strategies and activities which strive for the condition, it cannot be ignored that more needs to be best AF patient care possible. Key transferable elements done to ensure optimal protection for patients against and learnings have been drawn out of these examples for AF-related stroke.5 practical application, supported by identification of remaining misperceptions that are currently challenging optimal AF It is estimated that the true number of people living with patient care. Throughout the report you will see quotes AF in England is over one million, including around 250,000 from the meeting attendees and contributors. living with undiagnosed AF.6 Therefore, it is essential that appropriate screening methods and activities are in place While we have come a long way, and there are many to identify those with AF, make a complete diagnosis and championing quality care, there remain thousands of AF implement appropriate care.5 Yet, even following a diagnosis patients needlessly suffering an AF-related stroke, that of AF and accurate assessment of stroke risk, the patient may kill them or leave them disabled for life. pathway to appropriate anticoagulation is fraught with This situation needs to change, and it is critical that all challenges, leaving over half of diagnosed AF patients not on individuals involved in the AF patient pathway strive to take anticoagulation7 and exposed to the risk of AF-related stroke. patient care from good to excellent, to ensure AF patients With the updated NICE clinical guideline on the management and those around them are protected from the devastation of atrial fibrillation published in June 2014, there is a spotlight of AF-related stroke. on the importance of appropriate management of AF patients. The guidance suggests that non-vitamin K (“novel”) oral anticoagulants (NOACs) should be an option for stroke prevention in such patients, and that aspirin should not be offered solely for the prevention of AF-related stroke. Yet, in practice these recommendations are often not happening, which is unacceptable. I am therefore pleased to introduce the In Pursuit of Excellence in the Prevention of AF-Related Stroke report. Trudie Lobban MBE, FRCP Edin This report captures insights and discussion from a multi- Founder & CEO, AF Association stakeholder group, generated as part of a roundtable meeting and through follow-up with experts, to assess the current situation for the management of AF patients in England, including challenges to optimal care, best practice examples and practical solutions. In Pursuit of Excellence – 03 THE TRUE PRICE OF AF-RELATED STROKE Without preventative action there is likely to be an increase in the incidence of stroke as the population ages. Stroke is one of the top causes of death in England, and even those who survive often need care for some time after their stroke and potentially the rest of their lives.8 The devastating impact also extends beyond the sufferer, putting significant emotional and financial strain on those around them.8 Atrial fibrillation (AF) is the most common cardiac rhythm disorder1,9 and a major risk factor for stroke.8,10,11 It increases the risk of a clot developing in the heart, which may then get pumped into the general blood circulation and travel to the brain, where it can block arteries, causing a stroke.4,9,12 AF-related strokes are also more severe, with greater disability and mortality than strokes not attributable to AF.2,4 The risk of AF-related stroke is greatly reduced with appropriate anticoagulation.5,10,13 Yet, many AF patients remain undiagnosed, and even those diagnosed may remain unprotected against AF-related stroke. Burden of stroke Relationship between AF and stroke • There are approximately • AF is a powerful independent risk factor 3 10 110,000 strokes per year for stroke, increasing risk by around 500% 5 in England;8 this equates 1 stroke minutes to around one stroke every every five minutes • Stroke is one of the top three causes of death and % the largest cause of adult disability in England8 Around one in four people who experience 500 a stroke will die as a result8 • Approximately 12,500 strokes a year Around half of those who do survive a stroke will are thought to be directly attributable be left dependent on others for everyday activities8 to AF8,10 12,500 Around 300,000 people are living with moderate to severe disabilities as a result of stroke8 • AF-related stroke is also often more severe than in people without AF including longer stays in hospital, greater • Stroke is more common in men than in disability, higher rates of recurrence and mortality2,4 women, but women who suffer a stroke are more likely to die of it 8 • Of those AF patients experiencing a stroke, 4,300 will die in hospital and 8,500 will die within the first year following the stroke14 • It is estimated that £8 billion stroke costs the a year for the economy economy around 4,300 8,500 including £8 billion a year, will die in hospital will die within the first year which includes a cost of over £3 • Healthcare costs in the first year of care following an 3 billion to the NHS8 £ billion 10 to the NHS AF-related stroke are estimated to be up to £11,900 04 – In Pursuit of Excellence AF picture in England Management of AF 2016 2017 2018 • Around • There is an average delay of 2.6 years between onset of symptoms and diagnosis of AF18 35, 8 000 • Among patients with documented chronic AF: people in England are known to have AF15 More than a third were not aware of • However, it is estimated that there may be another their diagnosis19 250,000 living with undiagnosed AF,6 so the true number of those living with AF could be over one million • Prevalence of AF increases with age, occurring in around 10% of people aged over 6516 and 15% of people aged Up to half were unaware 75 and over1 of why they were being treated19 % 10 % 15 • An estimated 7,000 AF-related strokes could of people aged over 65 of people aged 75 and over be prevented and 2,100 lives could be saved every year, if AF was appropriately managed with anticoagulation13 • Men are more commonly affected by AF than women, at a ratio of almost 7,000 2,100 7 two to one AF-related strokes lives could be saved could be prevented • Between 100,000 Every year and 200,000 people • Yet, over half of diagnosed AF patients develop AF every are prescribed aspirin or nothing at all, year in the UK17 leaving them unprotected against the risk of AF-related stroke7 In Pursuit of Excellence – 05 AF MANAGEMENT GUIDELINES IN PRACTICE To protect more AF patients against the devastating effects of AF-related stroke, and reduce the number of preventable AF-related stroke deaths, it is fundamental that AF is detected and diagnosed in a timely manner, and that AF patients are appropriately anticoagulated. NICE guidance on AF management While warfarin can be an effective option to reduce the risk of AF-related stroke, when patients remain within the optimal The updated National Institute for Health and Care Excellence therapeutic range, there are a number of challenges for some (NICE) guideline on the management of atrial fibrillation, patients including many food, drink and drug interactions, issued June 2014, marks the first update in eight years and the need for regular international normalised ratio (INR) following the 2006 guideline. monitoring.20 The NOACs overcome many of these challenges, The update takes into account the introduction of making them appropriate alternatives for many patients.21 non-vitamin K (“novel”) oral anticoagulants (NOACs), and associated technology appraisal guidance for individual A look at the picture since updated NOACs recommending them as therapy options.