Download Anticoagulation in atrial fibrillation: delayed implementation of

Policy in Practice
Anticoagulation in atrial
fibrillation: delayed
implementation of evidence
Jenny Tagney, Cardiology Nurse Consultant, The Bristol Heart Institute, Bristol.
Email: [email protected]
A
trial fibrillation (AF) is a common heart rhythm
disorder whereby deranged electrical impulses in
the atria prevent effective atrial contractions,
allowing blood to pool with the potential formation of
emboli. Approximately 1–2% of the general population is
affected. Symptoms may include palpitations, shortness of
breath, fatigue and lethargy but people may be
asymptomatic or unaware that they have the condition.
While the condition itself is not life-threatening,
AF-related ischaemic stroke is of particular concern and
evidence suggests that stroke risk remains constant whether the individual has prolonged, permanent or paroxysmal
AF (Friberg et al, 2010). One in five strokes is attributed to
this arrhythmia and these are more likely to be fatal than
other causes of stroke, with survivors more severely disabled (Camm et al, 2010). Assessment of stroke risk in
people with AF was previously calculated using CHADS2
to identify risk factors associated with a higher incidence
of stroke (Camm et al, 2010).
However, this evolved into a more sensitive instrument,
the CHA2DS2-VASc (Lip et al, 2010; Olesen et al, 2011) to
inform stroke risk calculation and thus support prescribing decisions regarding the need for anticoagulation. The
acronym and scoring system are explained in Table 1.
A score of one or more in the CHADS2 or ≥2 in the
CHA2DS2-VASc means that thromboprophylaxis is indicated. Use of tools to assist with assessment of bleeding
risk such as the HAS-BLED score (Pisters et al, 2010) is
also recommended to further inform the risk/benefit ratio
for both patients and prescribing clinicians (Camm et al,
2010).
Therefore, the focus of assessment and treatment for
individuals with AF is not only aimed at controlling or
relieving symptoms, but also at reducing stroke risk
through identification of individuals who would benefit
from thromboprophylaxis. Evidence regarding what is
considered most effective in this regard has previously
supported use of aspirin (National Institute for Health and
Care Excellence (NICE), 2006; Camm et al, 2010).
However, evidence for benefits of aspirin, either alone or
in combination with other antiplatelet agents, to reduce
stroke risk is weak—yet, its potential to increase risk of
bleeding is similar to that of anticoagulants (Camm et al,
2012). Thus revised European guidelines in 2012 strongly
British Journal of Cardiac Nursing
August 2015
Vol 10 No 8
recommended use of anticoagulants, with aspirin use
reserved only for people who refused these (Camm et al,
2012). While previously warfarin was the only anticoagulant available, requiring frequent blood testing to monitor
individual clotting levels threatening concordance, the
development of novel non-vitamin-K antagonist anticoagulants provides a more acceptable, yet still cost-effective
alternative (NICE, 2014a). However, as these medications
are relatively new additions to national prescribing formulary and currently only licensed for use in patients with
non-valvular AF, familiarity and confidence regarding
their use may take some time to develop.
In light of the potential to reduce the risk of stroke if AF
is detected and anticoagulation commenced, significant
work has been undertaken in the UK to improve knowledge and awareness of both assessment and treatment.
GRASP-AF is an audit tool developed to assist primary
care practices in identifying patients diagnosed with AF
via their practice records (NHS Improving Quality
(NHSIQ), 2012). The tool is designed to ensure that practices are compliant with requirements of the Quality
Abstract
Prescribing evidence-based medications and keeping up-to-date
with new evidence is a requirement for both medical and nonmedical prescribers (Nursing and Midwifery Council (NMC), 2006).
In considering how new evidence is incorporated into practice, it is
clear that there can be a considerable lag before new, authorised
and recommended treatments are assimilated. The following case
study illustrates the potential for conflicting advice that can arise
as a result of inconsistent guidance and lack of awareness of
updated evidence for treatment of specific conditions. Further,
benefits of shared decision making between patients and clinicians
and their potential application between clinicians in such situations
is highlighted. The importance of specialist nurses in facilitating
both education and access to new evidence is identified, as is the
need for effective and timely communication to secure judicious
implementation of changes in policy and practice.
Key words
w Atrial fibrillation w Guidelines w Specialist nurses
w Stroke risk assessment
Submitted for peer review: 18 May 2015. Accepted for publication: 21 July 2015.
Conflict of interest: None.
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Policy in Practice
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if there might be a rhythm disturbance. His pulse was
regular in clinic and his electrocardiogram (ECG) showed
sinus rhythm. To investigate further, the author arranged
for an ambulatory cardiac monitor to assess for any
arrhythmias.
When the results of this were analysed, episodes of paroxysmal AF were demonstrated. In applying the
CHA2DS2-VASc scoring system (Lip, 2011), he scored
two—one point for hypertension and one for his age
(range 65–74). Thus he met primary stroke prevention
criteria for anticoagulation, which was explained to him
via a letter that was copied to his GP requesting that this
was commenced. Mr Bloggs telephoned a week or so after
the letter was sent to say that after discussion with his GP,
they had decided that he only really needed aspirin as,
according to his CHADS2 score of one (for hypertension),
he was only at low risk of stroke.
As a result of current specialist knowledge, it was possible to effectively explain to Mr Bloggs why aspirin was
no longer recommended and identify how the evidence
that he and his GP were employing had been updated.
Further, owing to an awareness of the existence of conflicting guidance for GPs, it was possible to identify precisely
where the error in information occurred. Mr Bloggs was
grateful for further explanations but requested that a further letter be written to him and his GP including additional information to guide the prescription of anticoagulation.
Discussion
Outcomes Framework (QOF) (NHS Employers, 2013).
These requirements included identifying patients with AF
and ensuring that they were treated according to current
guidelines. Within this framework, the CHADS2 scoring
system (rather than the more sensitive CHA2DS2-VASc
system) and use of aspirin were still recommended in
2013/14, stating that this was ‘in accordance with ESC
guidelines’ (citing the 2010 guidance) despite revised
guidance from the ESC being published in 2012.
Thus, despite updated empirical evidence that antiplatelets were not effective in stroke prevention in patients with
AF, GPs were still incentivised to prescribe them. In July
2014, NICE also released revised guidelines for the assessment and management of AF that specifically recommended against prescribing aspirin for stroke prevention
in AF (NICE, 2014b). It is against this background that the
following case study is set.
Case study
Mr Bloggs (pseudonym) was a 67-year old man who was
referred to a cardiology clinic by his GP. Mr Bloggs was a
lifelong non-smoker but was treated for hypertension.
In describing his symptoms, Mr Bloggs mentioned
occasions where he felt his pulse `race’, with a fluttering
feeling in his chest. While these symptoms were not particularly troublesome, he mentioned them as he wondered
2
It is not usual practice in all cardiac centres to bring
patients back to secondary care when results of investigations are reported unless any ensuing treatment requires
initiation within a secondary care setting. However, as can
be seen from the case study of Mr Bloggs, this can mean
that there is insufficient opportunity to engage in an open
dialogue with patients regarding proposed treatment
options and an over-reliance on primary care clinicians to
provide this.
The term ‘shared decision making’ (SDM) is used to
describe clinical decisions arising from discussions
between clinicians and patients regarding proposed treatment. Key components of SDM are identified as providing
(Elwyn et al, 2012):
ww Information
ww Opportunities to explore and deliberate options with
patients
ww Support for patients to make an informed choice regarding the option that best suits them.
However, within this example, it seems that correspondence and collaboration with Mr Bloggs’ GP may also have
benefitted from the SDM approach. The decision reached
by Mr Bloggs and his GP after receiving recommendations
based on an investigating clinician’s analysis suggests that
insufficient evidence had been provided to support the
rationale to either Mr Bloggs or his GP. Good communication and ensuring evidence-based practice are key standards within the NMC (2006) standards for prescribing.
British Journal of Cardiac Nursing
August 2015
Vol 10 No 8
Policy in Practice
As AF is such a common condition and there had been
local educational efforts aimed at updating GPs’ knowledge and awareness of assessment and treatment, a more
cooperative response was anticipated from this GP.
However, such educational efforts may not reach all GPs.
Therefore, any guideline is only effective if clinicians are
aware of and implement its content, which can cause both
delays in treatment initiation and inappropriate prescribing practice. In England, GPs’ practice is guided by the
QOF (NHS Employers, 2013), which is apparently not
quickly responsive to changes in evidence.
If GPs are aware of updated evidence, they may choose
to incorporate this as a principle of ‘best practice’, yet their
‘performance’ in relation to the QOF would be penalised
if they do. Therefore, in order to ensure that primary care
clinicians are kept abreast of specialist practice developments, it seems that a two-pronged approach may be
indicated.
From a policy perspective, it is essential that there is
timely communication between relevant policy development bodies and practice governing bodies such as NICE,
NHS England and speciality guideline development
groups to ensure such conflicting guidance does not jeopardise safe prescribing. From a personal responsibility
perspective, this issue has been discussed within local
cardiology clinical forums. An agreed development is that,
specifically where such potential conflicts have been identified, a one-page printed overview of the updated clinical
guidance will be provided with references for further
reading by primary care clinicians if desired.
However, there remains the potential for guidance from
specialists to be ignored unless there is a willingness
among non-specialist clinicians to engage and a shared
understanding of what constitutes best practice. Barriers
to implementation of specialist guidelines in primary care
settings are also not limited to AF (Grol, 2001; Chenot et
al, 2008).
In anticipation of potential barriers to implementation
of the new NICE (2014b) AF guidelines, an implementation collaborative consensus document was developed as
part of the implementation programme focusing on the
exclusion of aspirin from treatment options and supporting novel non-vitamin-K antagonist anticoagulants
(NICE, 2014a). This brings together the evidence for anticoagulation in non-valvular AF and adopts a ‘frequently
asked questions’ approach to how information is presented. Still, it is not clear how many primary care clinicians
this information may reach and further, how many will
feel confident to incorporate it into their practice.
Therefore, it seems that a multifaceted approach is likely
to be most effective in ensuring that new guidance is both
highlighted and implications for practice explained to
non-specialist clinicians. Wherever possible, this should
include direct communication regarding a specific patient
so that practical issues relating to that individual may be
considered. Additionally, providing practice nurses and
practice managers with easy to follow summaries of new
treatment guidelines may further support both patients
British Journal of Cardiac Nursing
August 2015
Vol 10 No 8
Table 1. Original CHADS2 tool with the
development to CHA2DS2VASc scoring
Risk factor
Score
C ongestive heart failure/left ventricular dysfunction
1
H ypertension
1
A ge ≥ 75
2
D iabetes
1
S troke/TIA/thrombo-embolism
2
V ascular disease
1
A ge 65-74
1
S ex category (female)
1
Source: adapted from Lip, 2011
and GPs. Finally, it is imperative to ensure that the patient
is fully cognisant of treatment indications and any available options so that they are empowered to guide their own
treatment and everyone is clear regarding their choice.
This case study has identified that lack of up-to-date
specialist knowledge and delays in implementing clinical
guidelines in primary care may give rise to conflicting
information being given to patients regarding most effective treatment. While specialist nurses can act to facilitate
education and raise awareness to an extent, it will be difficult to ensure that such approaches reach every relevant
clinician or that those clinicians will feel confident to
change their practice. Shared decision making models
may help to ensure that both individual patients and their
primary care clinicians are provided with information and
opportunities to explore potential options through direct
discussion with a specialist clinician. Through this collaborative approach, it is anticipated that patients will feel
supported in their treatment choices and non-specialist
clinicians will feel supported in implementing recommendations from clinical guidelines. BJCN
References
Camm AJ, Kirchhof P, Lip GY et al; European Heart Rhythm
Association; European Association for Cardio-Thoracic Surgery
(2010) Guidelines for the management of atrial fibrillation: the Task
Force for the Management of Atrial Fibrillation of the European
Society of Cardiology (ESC). Eur Heart J 31(19): 2369–429. doi:
10.1093/eurheartj/ehq278. http://tinyurl.com/pl73w9w (accessed 21
July 2015)
Camm AJ, Lip GY, De Caterina R et al; ESC Committee for Practice
Guidelines (CPG) (2012) 2012 focused update of the ESC Guidelines
for the management of atrial fibrillation: an update of the 2010 ESC
Guidelines for the management of atrial fibrillation. Developed with
the special contribution of the European Heart Rhythm Association.
Eur Heart J 33(21): 2719–47. doi: 10.1093/eurheartj/ehs253. http://
tinyurl.com/ofkb5nv (accessed 21 July 2015)
Chenot JF, Scherer M, Becker A et al (2008) Acceptance and perceived
barriers of implementing a guideline for managing low back in
general practice. Implement Sci 3: 7. doi: 10.1186/1748-5908-3-7.
http://tinyurl.com/nfkf8c4 (accessed 21 July 2015)
Elwyn G, Frosch D, Thomson R et al (2012) Shared decision making: a
model for clinical practice. J Gen Intern Med 27(10): 1361–7. http://
tinyurl.com/ozqb2mq (accessed 21 July 2015)
Friberg L, Hammar N, Rosenqvist M (2010) Stroke in paroxysmal atrial
fibrillation: report from the Stockholm Cohort of Atrial Fibrillation.
Eur Heart J 31(8): 967–75. doi: 10.1093/eurheartj/ehn59. http://
tinyurl.com/pr2tshy (accessed 22 July 2015)
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Policy in Practice
Key Points
w
Assessment of stroke risk is a crucial part of treatment for atrial
fibrillation
w
Treatment guidelines may lag behind a fast-developing evidence base
w
Shared decision-making models may also apply between clinicians,
rather than only between clinicians and patients
w
Specialist nurses can play a key role in supporting patients and nonspecialist clinicians to understand evidence to support treatment
decisions
Grol R (2001) Successes and failures in the implementation of evidencebased guidelines for clinical practice. Med Care 39(8 Suppl 2): II46–
54
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining
clinical risk stratification for predicting stroke and thromboembolism
in atrial fibrillation using a novel risk factor-based approach: the
euro heart survey on atrial fibrillation. Chest 137(2): 263–72. doi:
10.1378/chest.09-1584. Epub 2009
NHS Employers (2013) 2013/14 general medical services (GMS)
contract quality and outcomes framework (QOF). http://tinyurl.com/
nzowd8o (accessed 21 July 2015)
NHS Improving Quality (2012) Guidance on Risk Assessment and
Stroke Prevention for Atrial Fibrillation (GRASP-AF). http://tinyurl.
com/o7s7hjr (accessed 21 July 2015)
National Institute for Health and Care Excellence (2006) Atrial
fibrillation: The management of atrial fibrillation. NICE, London.
http://tinyurl.com/nlyqsge (accessed 21 July 2015)
National Institute for Health and Care Excellence (2014a) NICE
Implementation Collaborative Consensus. Supporting local
implementation on the use of the novel (non-vitamin K antagonist)
oral anticoagulants in non-valvular atrial fibrillation. http://tinyurl.
com/nouqdb2 (accessed 21 July 2015)
National Institute for Health and Care Excellence (2014b) Atrial
fibrillation: the management of atrial fibrillation. [CG 180]. http://
tinyurl.com/nfnhfbp (accessed 21 July 2015)
Nursing and Midwifery Council (2006) Standards of proficiency for
nurse and midwife prescribers. NMC, London. http://tinyurl.
com/957l99p (accessed 21 July 2015)
Olesen JB, Lip GY, Hansen ML et al (2011) Validation of risk
stratification schemes for predicting stroke and thromboembolism in
patients with atrial fibrillation: nationwide cohort study. BMJ 342:
d124. doi: 10.1136/bmj.d124
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010)
A novel user-friendly score (HAS-BLED) to assess 1-year risk of
major bleeding in patients with atrial fibrillation: the Euro Heart
Survey. Chest 138(5): 1093–100. doi: 10.1378/chest.10-0134. http://
tinyurl.com/pkjskb6 (accessed 21 July 2015)
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