NICE has published a new quality standard which sets out priorities for healthcare professionals on the treatment and management of atrial fibrillation (AF) in adults.

AF is the most common heart rhythm disorder and is thought to affect around 900,000 people in England. It occurs when the electrical impulses controlling the heart rhythm become disorganised, so that the heart beats irregularly and, occasionally, too fast and so cannot pump blood around the body efficiently.

AF leads to deterioration in the function of the atria (the upper chambers of the heart which receive blood returning to it from other areas of the body) and prevents complete expulsion of blood from the heart.

People with AF have a higher risk of having a stroke because the blood can become stagnant and form blood clots. Anticoagulation therapy can help to prevent strokes by reducing the likelihood of a blood clot forming.

The quality standard includes 6 statements aimed at healthcare professionals caring for people in danger of developing, or who already have, AF. These include:

  • Adults with a type of AF called 'non-valvular' who have a stroke risk score of 2 or more (as estimated by their doctor using the CHA2DS2-VASC risk score) are offered treatment with an anticoagulant to lower their risk of having a blood clot that could cause a stroke.
  • Adults with atrial fibrillation who are prescribed an anticoagulant talk with their doctor at least once a year about the types of anticoagulants they could have and the advantages and disadvantages of each.
  • Adults with atrial fibrillation who are taking a type of anticoagulant called a vitamin K antagonist (such as warfarin) have regular blood tests to check whether the dose they are taking is at the right level to reduce their risk of stroke and bleeding problems.
  • Adults with atrial fibrillation who still have symptoms after treatment are referred within 4 weeks for specialised care that aims to ease their symptoms and reduce their risk of having a stroke or heart attack.
  • The quality standard also includes NICE's first developmental statementi on the provision and use of monitors (coagulometers) for people on long-term vitamin K antagonist therapy (such as warfarin) so they can check how well the treatment is working.

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE said: "Atrial fibrillation can be a distressing condition and people with it have an increased risk of having a stroke. Therefore it's important that people with AF have their condition managed effectively in order to eliminate the significant risk of stroke and prevent deterioration in their quality of life. This quality standard, by prioritising areas for improvement across the AF care pathway, will help to ensure that fewer people die unnecessarily as a result of poor treatment."

Dr Matthew Fay, a GP and specialist member of the committee that developed the standard, said: "This quality standard brings in to sharp focus the key issue of stroke prevention. In doing so it continues to highlight the need for a change in practice so that everyone with AF is considered for anticoagulation and the quality of that anticoagulation is always kept under review by clinicians and commissioning groups.

"The ineffectiveness of aspirin and the need to remove it from the AF patient pathway receives a much needed, and rare, negative statement. This should provide the impetus to those who still speculate on the value of aspirin from historic practice to have the discussion with their patients about the benefits of anticoagulation hopefully before, and not after a devastating stroke event."

Prof Beverley Hunt, Medical Director of Thrombosis UK and specialist member of the committee that developed the standard, said: "The NICE AF quality standard provides a minimum standard of care expected within NHS England. It demands that patients at high risk of stroke without a bleeding risk are offered blood thinners - either warfarin or the newer oral anticoagulants - but not aspirin. Every patient needs to decide with their health care professional which is most suitable for them and they should be reviewed annually. Those who self-monitor their warfarin with a home coagulometer should be supported. Lastly if treatment fails to control symptoms, then patients should be referred for specialist management within 4 weeks.

"These Quality Standards are important because without adequate blood thinners many patients would have a preventable stroke, and stroke can have a devastating impact on lives causing loss of movement, independent living and even death."

The full standard is available online at http://www.nice.org.uk/guidance/qs93