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2 Acknowledgements Rachel Rayment Graham Shortland Tristan Groves Sarah Holroyd Shakeel Ahmad Steve Gage Darrell Baker Fiona Walker Clare Evans Marilyn Rees Kay Jeynes Peter O Callaghan Navros Masani Martin Davies Brendan Boylan Anna Kuczynska Rosemary Kavanagh Haydn Mayo Gethin Morgan Sarah Morgan Kay Saunders Roger Morris Karen Pardy Simon Scourfield Joe Hunt Acute Response Team CAV UHB GP Clusters CAV UHB Cluster pharmacists

3 Scope of the problem: AF and stroke stroke survivors living in Wales 7000 strokes occur annually in Wales Patients with AF 5x more likely to suffer a stroke than those without AF Stroke is the 4 th largest cause of death in Wales 1000 strokes caused by AF in Wales each year 70% higher risk of death in stroke patients with AF than those without

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5 Evolution of risk management 1,2 CHADS 2 HEMORR 2 HAGES CHA 2 DS 2 -VASc HAS-BLED 2018 Guidelines recommend using the CHA 2 DS 2 -VASc score to estimate stroke risk in AF patients 2 Stroke risk factors are a CHA 2 DS 2 - VASc of 1 for men or 2 for women 2 CHA 2 DS 2 -VASc = 0 is the only score where net clinical benefit of warfarin < bleeding risk in patients with AF 3 HAS-BLED outperforms older bleeding scores in predicting major bleeding, and correlates well with intracranial haemorrhage 3 AF: atrial fibrillation; CHA 2 DS 2 -VASc: congestive heart failure, hypertension, age 75 (doubled), diabetes, stroke or transient ischaemic attack (doubled), vascular disease, age 65 74, and sex category (female); CHADS 2 : congestive heart failure, hypertension, age 75, diabetes, transient ischaemic attack (doubled), HAS-BLED: hypertension (i.e. uncontrolled blood pressure), abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR (if on warfarin), elderly (e.g. age >65, frail condition), drugs (e.g. aspirin, NSAIDs)/alcohol concomitantly; HEMORR 2 HAGES: hepatic or renal disease, ethanol abuse, malignancy, older age >75, reduced platelet count or function, re-bleeding risk, hypertension (uncontrolled), anaemia, genetic factors, excessive fall risk, stroke NICE Guidelines (CG180). Atrial fibrillation: the management of atrial fibrillation Available at: Last accessed: April Kirchhof P, et al. Eur Heart J 2016;37: ; 7; 3. Lip GYH. Eur Heart J 2013;34:

6 3. NICE CG180: Do not use aspirin monotherapy Do not offer aspirin monotherapy solely for stroke prevention to people with AF 1 In line with other international guidelines, NICE recommends that aspirin monotherapy is no longer a management option for AF: Aspirin confers only limited benefit in stroke risk reduction 2 Benefits are not offset by the associated increase in bleeding risk 2 AF: atrial fibrillation; NICE: National Institute for Health and Care Excellence. 1. NICE Guidelines (CG180). Atrial fibrillation: the management of atrial fibrillation Available at: Last accessed: April 2017; 2. Kirchhof P, et al. Eur Heart J 2016;37(38):

7 Why are OACs preferred to aspirin? Warfarin better Placebo better AFASAK I (1989, 1990) SPAF (1991) BAATAF (1990) CAFA (1991) SPINAF (1992) EAFT (1993) All trials* RRR 64%,* ARR 2.7% (95% CI: 49 74%) Compared to a 19% RRR, 0.8% ARR for aspirin 100 Random effects model; Error bars = 95% CI RRR (%) 100 AFASAK I: Atrial Fibrillation, ASpirin, AntiKoagulation; BAATAF: Boston Area Anticoagulation Trial for Atrial Fibrillation; CAFA: Canadian Atrial Fibrillation Anticoagulation; EAFT: European Atrial Fibrillation Trial; SPAF: Stroke Prevention in Atrial Fibrillation; SPINAF: Stroke Prevention in Nonrheumatic Atrial Fibrillation. 7 *P>0.2 for homogeneity; Relative risk reduction for all strokes (ischaemic and haemorrhagic). CI: confidence interval; OAC: oral anticoagulant; RRR: relative risk reduction. Hart RG, et al. Ann Intern Med 2007;146:

8 Bleeds/year Bleeds/year Aspirin use in NVAF Antiplatelet agents have limited efficacy in preventing stroke in patients with NVAF Major bleeding Intracranial bleeding ASA (n=61,396) OAC (n=48,599) HAS-BLED total scores* HAS-BLED total scores* Created from Friberg et al HAS-BLED n 8,919 34,944 62,140 46,417 15,644 20, *Modified HAS-BLED scored used in this study:1 point each for systolic blood pressure > 160 mmhgm rebak dysfunction, liver dysfunction, stroke, blleeding age>65 years, drugs affecting bleeding or alcohol abuse (maximum score = 7); score 0 2 indiicates low bleding risk, 3 indicates high bleeding risk ASA: acetylsalicylic acid, aspirin; HAS-BLED: hypertension (i.e. uncontrolled blood pressure), abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR (if on warfarin), elderly 8 (e.g. age 65, frail condition), drugs (e.g. aspirin, NSAIDs)/alcohol concomitantly; NVAF: non-valvular atrial fibrillation; OAC: oral anticoagulant; 1. Hart RG, et al. Ann Intern Med 2007;146:857 67; 2. Friberg L, et al. Eur Heart J 2012:33:

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27 The Primary Care Information Portal - Sample of potential displays of data

28 Stop a Stroke Portal Screenshots

29 RESULTS 29

30 CAV UHB AF Stop A Stroke: AIMS PRIMARY EFFICACY OUTCOME Reduce number of patients admitted to hospital with stroke Reduce ischaemic stroke Reduce intracranial bleeding (secondary to ASA / OAC) Reduce number of patients admitted with stroke on ASA SECONDARY OUTCOME Increase oral anticoagulation Reduce aspirin PRIMARY SAFETY OUTCOME No increase in bleeding 30

31 ANTICOAGULATION 31

32 CAV UHB AF patients prescribed OAC Apr Dec VKA LES May NICE CG 180 Jun 2014 AWMSG Sep 2014 NOAC LES Oct Taking Warfarin Taking NOAC TOTAL OAC

33 SAFETY 33

34 Number of AF patients admitted to UHW with a bleed on anticoagulation BLEEDS Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q

35 Number of AF patients admitted to UHW with a bleed on anticoagulation BLEEDS Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q

36 ASPIRIN 36

37 % (1687/6523) CAV UHB AF PATIENTS PRESCRIBED ANTIPLATELET MONOTHERAPY % (593/9315) /1/2014 1/1/2015 1/1/2016 1/1/

38 Patients with known AF on aspirin admitted to hospital with stroke

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