1. 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

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

3. 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

4. Results

5. 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

6. 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)

7. 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

8. 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

9. 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?

10. DOAC – correct dose
JACC 2016; 68: 2597

11. 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

12. Prediction

13. 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

14. 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

15. 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

16. 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)

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