Reducing strokes

The Stroke Association looks at what can be done to prevent atrial fibrillation related strokes

Atrial fibrillation (AF) is one of the biggest health challenges we face in stroke prevention. Not only is it often undetected, but changes in the guidance on how to treat it are not being implemented. At the Stroke Association we worked with Public Health England (PHE), the Royal College of GPs (RCGP) and the Royal College of Physicians (RCP) to pull together data and insights and understand where and how we can improve AF management.
There are around 1.4 million people living with AF in England yet over a third of them are undiagnosed. This is important because AF presents a very serious stroke risk – in fact, the risk of stroke increases five-fold for people with AF. Not only does it increase the likelihood of having a stroke, AF related strokes are often more severe, with higher mortality and greater disability.
AF is, in very simple terms, an irregular heartbeat. The heart doesn’t beat properly so blood can pool in the heart chambers that can turn into clots. These clots can be pumped out of the heart and travel in the blood stream to a blood vessel in the brain, blocking the blood supply and causing an ischaemic stroke.
We know that AF is a contributing factor to 20% of strokes in England, Wales and Northern Ireland. This is despite clear guidance that outlines how AF related strokes can be prevented. The National Institute for Health and Care Excellence (NICE) guidelines on AF were updated in 2014, stating that all patients with AF should be considered eligible for anticoagulation treatment, and where appropriate prescribed an anticoagulant such as apixaban, dabigatran, rivaroxaban or a vitamin K antagonist such as warfarin that have been proven to effectively reduce a person’s risk of stroke.
The guidance is clear that aspirin monotherapy does not reduce stroke risk in patients with AF. Despite this advice we know that of the people who have been diagnosed, quality and outcomes framework (QOF) data shows 31% of eligible patients on the AF register are not being given anticoagulation treatment.
In England more than half of stroke patients admitted to hospital in AF are not receiving full anticoagulation treatment (Figure 1). Rates of anticoagulation in those with known AF have only increased by 4.4% (36.8 – 41.2%) since the introduction of the guidelines last year. These figures are for England only, so we currently do not know what the picture looks like for those with AF in Scotland, Wales and Northern Ireland.

Commissioners’ roles
Commissioners play a vital role in ensuring people with AF are detected and treated to reduce their risk of a devastating stroke (Figures 2 and 3). To support this, the Stroke Association, in partnership with the RCP, PHE and RCGP created AF: How can we do better? – (see Resources), a freely available, downloadable document showing how each CCG is performing in relation to AF care.

AF related strokes are preventable. If the 1.4 million people with AF in England were detected and then adequately treated, around 7,000 strokes would be prevented and 2,100 lives would be saved every year. In addition to reducing deaths and severe disability, additional health and social care costs could be avoided.
The AF: How can we do better? report compares AF diagnosis and treatment rates by CCG and show that there is significant variation. Around 65% of people who are estimated to have AF are diagnosed overall in England. However, looking at the data from CCGs it shows the diagnosis rate ranges from 39% in the worst performing area to 88% in the best. The data we used comes from the QOF, PHE, Sentinel Stroke National Audit Programme (SSNAP) and NHS Improving Quality (NHSIQ), enabling us to compile a comprehensive summary of AF care.

The next step
The challenge now is to put this evidence into use to support consistently high quality AF care and prevent more strokes. To do this, we have worked with a group of GPs, nurses and community pharmacists from the Primary Care CVD Leadership forum to pull together expertise and advice that CCGs can use to improve case finding and anticoagulation practice and improve stroke prevention. The advice is outlined in full in AF: How can we do better? Below is a short summary of key steps that CCGs can take now to find undiagnosed AF patients and ensure they are well managed to reduce their stroke risk.
1 Download your tailored resource pack from stroke.org.uk/professionals/af-how-can-we-do-better.
2 Compare recorded and expected prevalence across the CCG to estimate
the total number of people with undiagnosed AF.
3 Use QOF data to estimate how many people with AF in the CCG are not anticoagulated.
4 Examine the level of variation in detection and anti-coagulation rates between practices within the CCG. What are practices doing differently?
5 Support practices to use tools such as GRASP-AF to audit performance and improve case finding.
6 Add pulse checking to local enhanced service specifications where appropriate.
7 Ensure all eligible patients receive the NHS Health Check, which will systematically detect abnormal pulse rhythms as part of blood pressure measurement.
8 Ensure local practices have access to quality assured ECG interpretation.
9 Explore potential for community pharmacists to offer pulse checking as well as adherence support for anti-coagulants.
10 Ensure a robust local pathway for prescription and monitoring of NICE approved NOACs and warfarin
11 Explore potential for self-monitoring of anticoagulant control.
More detail can be found in AF: How we can do better? and additional resources for professionals are available (see Resources).
AF is a priority for the Stroke Association. An AF related stroke should be considered a preventable stroke. The evidence shows that simple measures make a huge difference to stroke prevention. We want to support commissioners and GPs to find and treat more people with AF and ultimately, to prevent devastating strokes.