Uttam M Chouhan Pharmacist Glan Clwyd Hospital, BCUHB September 2017 What’s happening in Denbighshire to reduce atrial fibrillation related strokes? Uttam M Chouhan Pharmacist Glan Clwyd Hospital, BCUHB September 2017

Aim To increase the uptake of stroke prevention treatment in eligible atrial fibrillation (AF) patients in primary care.

What has been done? Cardiac network, with pharmacy support, taking ownership of this initiative Educational grant from 3 pharmaceutical companies to recruit pharmacists Invitation to GP practices No AF register – search GP systems to identify AF patients & their CHA2DS2-VASc scores Gave concise education to healthcare professionals on oral anticoagulants Invited AF patients with CHA2DS2-VASc score ≥ 2 not on stroke prevention treatment

Results

Results 270 patients accepted appointments F 111 & M 159 Mean age 77 years 40 (15%) patients did not attend, mean age 79 (57-97) 59 (22%) evidence of AF lacking

Results - referrals Sought consultant advice in 47 patients eg to confirm diagnosis of AF 94 yr, f – long term amiodarone, PAF, iron deficient 70 yr m – PAF on discharge letter, IHD, diabetes ICH patients (6) – no to OAC ? Referrals from nurses – 13 warfarin patients with low time in therapeutic range (TTR)

Results Aspirin stopped in 27 patients (10%) No clinical indication Age range 67 to 94 years, mean 80 years Anaemia in 16 patients, mean age 83 Aspirin for secondary prevention Lancet online 13th June 2017

Results- eligible for anticoagulation Refusal by patients 47, mean age 77 years Accepted OAC in 52, mean age 78 No baseline FBC & U/E in 28

DOAC - observations In 4 GP practices, advice to Record weight Monitoring not uniform & no follow up Hb dropping (stopped treatment in at least 4 – Hb < 100) Dose reduction due to renal impairment (Calculator) Stopped dabigatran when < 30mL/min 20% of patients needed dose adjustments Why bother?

DOAC – correct dose JACC 2016; 68: 2597

AF strokes YGC Jan to May 2017 32 patients with known AF admitted with strokes 20 (62%) no stroke preventative treatment 4 out 5 patients on warfarin INR out of range Helen Thomas, Specialist Stroke Nurse, YGC 6th June 2017

Prediction

What went well? Initiative started in defined geographical area with involvement of willing GP practices INR control in established warfarin patients is good (≥ 70% of patients have TTR ≥ 65%) Interaction with secondary care colleagues to resolve issues around AF diagnosis & stroke prevention treatment

What could be better? 1 in 4 eligible AF patients with risk factors on either aspirin or no stroke prevention treatment No national system to identify AF patient population and their CHA2DS2-VASc & HASBLED scores Protected time to provide educational information on oral anticoagulants to all healthcare professionals including nursing colleagues Built in prompts within GP systems when routine blood tests should be performed in patients on warfarin or direct acting oral anticoagulant (DOAC) & adjust dose

What could be better? Promote preventative stroke treatment to increase “buy in” from AF patients in primary care Increase awareness to fully utilise information within the INRStar system Adapt INRStar to keep records of patients on DOAC Update local AF guidance to reflect ESC 2016 guidance used by cardiologists

Conclusions Project ends in September 2017 Stroke prevention in AF is possible There are benefit in continuing this project 35 strokes in Denbighshire could be prevented Need more “buy in” from patients All patients on OAC need to be monitored DOAC doses need to be correct (use the calculator)

Thank you Staff in GP practices Cardiac Network & Pharmacy YGC Claire Spencer Dr Graham Thomas Dr Matt Davies, GP Lead, South Denbighshire