GPs told to offer 'personalised care package' to AF patients

GPs should offer AF patients a 'personalised package of care' to help them become more involved in decisions about their care and better understand their risk of stroke, according to updated NICE guidance.

NICE guidance seeks to involve AF patients more in their care (photo: Jason Heath Lancy)
NICE guidance seeks to involve AF patients more in their care (photo: Jason Heath Lancy)

The care package should offer advice and support to help involve patients in managing, understanding and making informed decisions on treatment for their condition.

NICE's guidance said this package should also give patients information on treatment with anticoagulants, including how to use them, possible side-effects, how their care will be monitored, and when and how to seek medical help.

A GP who co-authored the NICE guidance insisted it would not increase GP workload, but would help patients make decisions about their care.

The advice forms part of the first update to NICE's AF management advice since 2006. The latest advice called for wider use of new oral anticoagulants as part of a bid to prevent up to 7,000 strokes a year.

But NICE advised GPs not to prescribe aspirin for stroke prevention, saying the bleeding risk from taking the drug to treat low-risk AF outweighed the 'questionable' benefits.

Around 200,000 AF patients – around 25 per GP practice in England – currently take aspirin to reduce their risk of stroke.

NICE said patients should visit their GP to consider alternative treatment with anticoagulants, but advised GPs that this was ‘not urgent’ and could be carried out opportunistically.

Prescribe anticoagulants

In the guidance, NICE said GPs should consider the full range of oral anticoagulants, including apixaban, dabigatran etexilate, rivaroxaban, or a vitamin K antagonist.

NICE noted that the new generation oral anticoagulants do not require regular monitoring as does warfarin. It estimated that up to a half of patients currently prescribed warfarin have inadequate dosage control.

Members of the guideline development group said wider prescribing of the new oral anticoagulants may push up primary care prescribing costs. The new oral anticoagulants are estimated to cost over three times as much as warfarin, excluding monitoring costs.

However, some of this extra cost may be offset by a reduced need to perform INR monitoring.

The CHA2DS2-VASc and HAS-BLED risk scores should be used to assess stroke and bleed risk respectively when deciding on treatment. GPs should offer anticoagulation to all patients with a CHA2DS2-VASc score of 2 or higher, NICE said.

No increase workload

Dr Matthew Fay, a GP and member of the guideline development group, insisted the updated guidelines would not mean more extra work for GPs. ‘With more than 10% of over 65 year olds having AF, GPs have to deal with both its identification and management on a regular basis,' he said.

'The NICE guideline builds on the relationship between the patient with AF and their GP, outlining how each patient should have a clear management plan which takes into account their personal preferences and the clinician’s view of the evidence that has been clearly laid out in the guideline.

‘This is not new work for general practice. I think most of us as GPs like to consider that we do always take the patients into the heart of decision making, and we should reflect the evidence to them and help them make decisions.’

NICE estimated that up to 7,000 strokes and 2,100 deaths could be prevented each year if the new guidance is followed.

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