According to a new survey, four in 10 AF patients in the UK are either receiving aspirin (28%), which has been deemed less effective for stroke prevention, or no treatment at all (10%), potentially leaving thousands of people in the UK at risk of stroke, with budget pressures on GPs cited as a major contributing factor1.
Effective anticoagulation can reduce the risk of stroke by two-thirds2 yet, just under half of patients are given warfarin to thin the blood which, whilst effective, involves complex monitoring to ensure it is kept within the therapeutic range for the individual patient and has dietary restrictions1. According to GPs, only one in 20 of their patients are prescribed the newer NICE approved, novel oral anticoagulants (nOACs) and only 22% of AF patients said they were told by their doctor that alternative OACs are available1. Over half (57%) of GPs surveyed said that they felt under pressure from their PCT to prescribe low cost medications for stroke prevention1.
Almost 7 in 10 of the surveyed stroke physicians (who are at the forefront of the impact of stroke) said that increasing the appropriate usage of nOACs, moving away from aspirin and warfarin, would help reduce strokes1 and that more than one in three strokes could be prevented if AF patients were spotted sooner and treated more effectively1. Nearly all (98%) of surveyed patients taking warfarin said they would prefer a more convenient once-a-day pill1. 83% of patients agreed that avoiding the routine coagulation monitoring, such as is required with warfarin, was important1.
Updated 2012 European Society of Cardiology (ESC) guidelines place the novel OACs at the centre of effective treatment, classing aspirin as largely ineffective in AF stroke prevention3. Failure to effectively treat AF currently costs the NHS over £3 million per year4. The Atrial Fibrillation Association (AFA) says that all AF patients at risk of stroke should be offered newer OACs5.
Dr. Khalid Khan, Consultant Cardiologist, BCUHB, (Wrexham) said: "One in four of us will develop AF in our life time. The most devastating complication of AF is that of stroke. The really good news is that we are easily able to estimate this risk for anyone with AF and take preventative action. We know that effective anticoagulation here reduces your chances of having a stroke enormously by 2/3. Today's findings, however, clearly illustrate why, every day, cardiologists and stroke physicians are still seeing the tragic consequences and loss of life caused by AF related strokes. This amounts to ~25,000 cases every year, many of which may have been preventable".
He continues: "These results echo findings from other studies regarding the situation around the UK, meaning that unfortunately there are many thousands of people with atrial fibrillation who remain unprotected and at an unnecessarily high risk of stroke. Whilst some patients with AF who are at low risk, do not require treatment, the vast majority do. So to see 4 out of 10 people not being anticoagulated is alarming. This survey underlines the considerable challenge ahead in tackling the inadequate treatment of patients at high risk. It is also notable that for those who are being anticoagulated, the vast majority are on warfarin, a drug which can be hard to use and requires variable dosing. In clinical practice, only two thirds of such patients are dosed to the correct level - the rest remain at risk of complications."
He concludes: "Every AF patient at risk has the right to be offered high quality and effective anticoagulation that is appropriate for them. This includes the use of modern anticoagulants that have been approved by NICE in the last two years. These are available as either a twice a day or a once a day pill and do not involve the need for complex monitoring. This can have a very positive impact on the quality of life for some patients allowing simple and effective protection whilst they get on with their lives. Increased knowledge of and access to these treatments, where clinically appropriate, must be supported now".
The survey also found that1:
- Less than a third (32%) of stroke physicians said they believe that AF patients in the UK are receiving the best possible treatment to reduce their risk of stroke, and 98% believe more could be done by GPs to provide more effective anticoagulation for stroke prevention.
- Half of GPs said they lack the confidence to use the newer drugs and over a quarter said they tended to prescribe drugs they knew more about.
- 70% of stroke physicians believe lack of knowledge is a barrier to GPs prescribing the newer treatments.
Trudie Lobban MBE, Chief Executive and Founder of the Atrial Fibrillation Association (AF Association) said: "Although UK services to detect AF appear to be improving, this survey's results confirm that much more needs to be done in managing patients' stroke risk adequately and we need to start by offering more support to primary care physicians and nurses.
We know that the outcomes are better for patients who are informed and involved in deciding their care and treatment with their doctor. It is disappointing that so few patients have access to optimal treatments such as the newer oral anticoagulants, which currently only account for 3.4% of all anticoagulant use.
During this annual AF awareness week (run by the AF Association), we are strongly encouraging GPs to download the free revalidation tool so they are equipped with the necessary knowledge and resources to reduce the massive burden that AF-stroke currently places on the health service and society. We also encourage all those who think they may be at risk of AF and those already diagnosed with the condition to visit our website for impartial information on the condition and treatments available".
Joe Korner, Director of External Affairs at Stroke Association said: "Atrial fibrillation increases your risk of stroke by up to five times and around 12,500 strokes a year are thought to be directly linked to the condition. This new survey, which suggests that AF patients are not receiving the treatment they need to lower their risk of stroke, is extremely worrying.
"We know that well over a fifth of people admitted to hospital with AF related strokes have not been given the appropriate anti-coagulation treatment - in other words their stroke could well have been prevented. The Stroke Association wants to see a step change in the recognition, diagnosis and treatment of AF to save many thousands of people from the trauma of stroke and to save the NHS the high cost of treating stroke. If you have AF or are at all worried about your risk, it is vital that you speak to your GP to discuss the treatment options available and choose the one that works best for you."
People with AF are at greater risk of a stroke because they are more likely to develop blood clots. These occur when the atria - the upper cavities of the heart - beat irregularly (fibrillate) and the blood stagnates and clots. When a clot forms it can dislodge and fly around the circulatory system. If it does not disperse it can get stuck, resulting in a stroke. While some patients exhibit symptoms such as palpitations, breathlessness, dizziness and chest discomfort, others do not but still need appropriate management.