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National Institute for Health and Care Excellence

Clinical Articles, Lead Article

Thousands of AF strokes avoidable, says NICE update

Thousands of people with atrial fibrillation (AF) suffer strokes, disability or death which are avoidable, according to new guidance published by the National institute for Health and Care Excellence (NICE) and produced by the National Clinical Guideline Centre.

Around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs that prevent blood clots forming, but only half of those who should be getting these drugs are, according to the update. It highlights the need to ensure people with AF are offered the right treatments to reduce their chance of dying from strokes.

A report, published to coincide with this guidance by an advisory group, known as the NICE Implementation Collaborative (NIC), highlights the steps needed to increase the uptake of novel oral anticoagulants (NOACs). Consensus group member Professor Neal Maskrey (Medicines and Prescribing Centre, NICE) said: “The NICE Implementation Collaborative has summarised key aspects of the new guidance around the use of the new generation of oral anticoagulants and recommends ways in which local practices can be adapted to deliver high quality treatment for people with AF.”

Dr Matt Fay (Westcliffe Medical Centre)

Dr Matt Fay (Westcliffe Medical Centre)

Member of the Guideline Development Group Dr Matt Fay (Westcliffe Medical Centre) said: “GPs have evidence-based tools on how to assess the patient’s personal stroke risk and their risk of bleeding and how to minimise that risk. The guideline incorporates the previous positive appraisals by NICE of the newer anticoagulants apixaban, dabigatran and rivaroxaban, positioning them clearly to enable the GP to support patients in their choice of preventive medication”.

Speaking to BJC Arrhythmia Watch, Dr Fay added: “When I first joined the NHS heart improvement programme in 2008, to highlight the issues around AF stroke prevention and anticoagulation, the project seemed quite clear. The 2006 NICE Guideline had already suggested anticoagulation for all but the CHADS2 low-risk cohort, (score 0–1 at the time) and the BAFTA study had published showing the benefits of warfarin in the older population for the same risk as antiplatlet agents.”

“However, AF was not high on the agenda, and clinicians had the comfort blanket of aspirin if they chose not to offer oral anticoagulation due to historic prejudice…Over the same time the political desire to prevent strokes, the development of non-vitamin K antagonists and the entry of the pharmaceutical companies in to the anticoagulation treatment area have pushed AF up the clinical agenda,” Dr Fay continued.

AF now “pushed up the clinical agenda”

“I have had the delight and privilege to present to many clinician and patient groups around the country over my time with NHS Improvement and , during these sessions, the evidence has been outlined and the supremacy of oral anticoagulation demonstrated, with only a very few clinicians openly clinging on to the aspirin comfort blanket. Yet when we review the GRASP Dataset from the CHART online today we find that with a third of the population now covered, the use of anti platelet agents sits at 34%,” he added.

“The NICE Guideline CG180 on AF has placed the patient at the centre of decision on stroke prevention, it has also removed antiplatelet agents completely from the management of AF. The Quality and Outcomes Framework will almost certainly follow. Hopefully this will finally remove the desire of some clinicians to treat themselves by giving patients aspirin and have an open and informed discussion of the options available. It is sobering to think, with the suggestion of how many potentially avoidable strokes are occurring each year due to aspirin, that since my involvement on the national stage for AF 42,000 people have suffered a needless stroke but for the sake of an anticoagulant,” Dr Fay concluded.

The NICE report is available in full at:

The full guideline is available to view on the National Clinical Guideline Centre website at

An interview with Dr Matt Fay can be viewed here:

Published on: June 26, 2014

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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