Atrial Fibrillation A National View Dr Matthew Fay General Practitioner Shipley West Yorkshire National Clinical Lead-NHS Improvement-Stroke

Acknowledgements •Dr Campbell Cowan •Dr Andreas Wolff •Dr Arindam Kar •Westcliffe Medical Practice

Costs associated with AF •12,500 strokes annually attributed to AF in UK •DH estimates of  costs of strokes attributable to AF •Total cost  £148 million in first year •Hospital stay cost £103 million •Post‐discharge care £45 million •Cost per stroke £12,000

Costs attributable to treating AF • Annual cost per patient £ 383 • Costs per stroke averted £9,572 • Additional costs due to major bleeds                     £ 236 – 349 / patient Treatment saves money and pays for itself

David Nicholson has set the challenge of saving £15-20 billion through efficiency savings from 2011 to 2014. The challenge to the NHS is how to make these savings whilst keeping quality as its organising principle

Role of the centre Improve quality and make efficiency savings

Quality improvements

Efficiency savings

The Department of Health’s role is to help the NHS prepare to meet the QIPP challenge, in line with the four principles of change: - Co-production - Subsidiary - Clinical leadership - System Alignment

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Stroke prevention in AF Detection of AF

Decision to anti-coagulate

Finding Atrial Fibrillation

Atrial Fibrillation •Commonest sustained Arrhythmia •Increasing in prevelence •Very common •Prevalence of 1.2% •600,000 case in England

PROJECTED AF PREVALENCE OLMSTED COUNTY DATA

12% observed increase in AF incidence between 1980 and 2000

Miyasaka et al, Circulation 2005; 114:119

Atrial Fibrillation •Commonest sustained Arrhythmia •Increasing in prevalence •Very common •Prevalence of 1.2% •600,000 case in England

Really?

Prevalence AF by practice

Direct Comparison

Fitzmaurice, D. A et al. BMJ 2007;335:383

Possible Solutions

Pulse Palpation at Flu Vaccination • Essex Cardiac & Stroke Network • Dr. Max Hickman, Chairman Colchester PBC Group • PBC Business Case August 2008 • LES agreed Sept 2008 [email protected]

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[email protected]

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Investigations • • • • •

Cardiovascular examination ECG BP BMI Cholesterol, glucose, creatinine

[email protected]

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Outcomes 37/43 practices in N E Essex Signed up to LES • 34,201 patients screened in 6 weeks – 3154 Patients found with irregular pulse (9.2%) – 189 Patients found with AF (0.55%) – 342 Patients found with other Arrhythmias (0.99%) including 2 in Complete H. Block! [email protected]

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The simple things in life… AF screening in General Practice

Dr Andreas Wolff

16%

National AF Prevalence in 2008: 1.3%

Whinfield Surgery AF prevalence 2008 = 1.32% Whinfield Surgery: patients aged 65 and over = 16%

Whinfield Surgery AF screening programme

Opportunistic computer prompted screening 5/08 – 5/09 1883 patients aged 65 years and older

1569 patients: pulse palpation

207 patients found with irregular pulse

130 patients with irregular pulse and no known AF

99 patients had ECGs

36 patients diagnosed with previously unknown AF ( +19 )

Key Facts • • • • • • •

83.3% screened opportunistically 13% with irregular pulse 6.3% had ECGs 36% had AF on ECG Number needed to screen 43 Change in prevalence 1.32 -> 1.82% Prevalence of 65ys and older: 10.9%

Stroke Prevention

Anticoagulation is underused and suboptimal in high  risk patients with atrial fibrillation who present with  a stroke ‐ 5 year data  Dr Maneesh Bhargava Dr Arindam Kar Dr Richard Perry Dr Diane Ames St Mary’s Hospital Imperial College NHS Trust

UK

Methods  y Retrospective analysis of 5 year stroke data from St  Mary’s Hospital Stroke Register (2003‐2008) – y

n=1297 total ischaemic strokes

y Subjects of interest – Pre‐existing AF or PAF y High risk stratification according to NICE 2006 criteria y No contraindications to anticoagulation y

• Data collected on – • Prior anticoagulant or antithrombotic use • Admission INR for those on warfarin

Results y 15% (187/1297) patients with ischaemic stroke were  known to have AF or PAF.

Results ‐ Demographics Patients with ischaemic stroke and known AF (n=187)

Results High risk as per NICE  guidelines: n=156/187

No documented  contraindication to  warfarin : n=131/156 

N=59/131

High risk patients with no contra‐indication to  warfarin : (n=131)

Results y Warfarin treated patients (n=35/131): ‐Sub‐therapeutic INR (