2. 1 GRASP-AF Audit - Intro 8 th July 2010 Mark Gregory

3. 2 Workshop Objectives  Phase 1 practices  Overview of GRASP-AF audit  Familiarity in running audit software  Practice pharmacists reviews  Audit timescales eg. data uploads

4. 3 What is Atrial Fibrillation ?  AF is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation and consequent deterioration of atrial mechanical function.  On ECG, there is an absence of consistent P waves; instead there are rapid oscillations or fibrillatory waves that vary in size, shape and timing.

5. 4 Atrial Fibrillation (AF)  Irregular heartbeat (arrhythmia)  Heart rate often faster than normal  Force of heartbeat variable intensity  Symptoms: palpitations, dizziness, angina, breathlessness  Or no symptoms!

6. 5 AF Classification  Paroxysmal  Persistant  Permanent  AF management pathways

7. 6 Prevalence of AF  Local pilot audits:  from 1.2% (ie. 12 per 1K patients)  to 2.6% (ie. 26 per 1K patients)  Aged 50-60 yrs: 1 in 200 people  Aged > 80: 1 in 10 people

8. 7 Key complication - Stroke  Risk of stroke increased x 5+  AF responsible for up to 30% of strokes  Big variation of stroke risk amongst AF patient ie. 2% to 12% risk pa  Antithrombotic treatment of AF based on risk of stroke

9. 8 AF Stroke Risk Assessment  CHADS2 Congestive heart failure + 1 Hypertension + 1 Age > 75 + 1 Diabetes + 1 (S2) previous stroke or TIA + 2

10. 9 CHADS2 stroke risk  CHADS2 score >1 = high risk of stroke (6% to 12% pa risk)  CHADS2 score 1 = medium risk of stroke (3% to 5% pa)  CHADS2 score 0 = low risk (1% to 2%)  Approx 70% of AF patients at high risk

11. 10 Warfarin vs Aspirin  Warfarin (INR 2.5) is significantly more effective than Aspirin 75mg  Warfarin strongly indicated if CHADS2 score > 1 point  CHADS2 score =1 Risks vs Benefits decision  Warfarin is under prescribed, particularly in the elderly

12. 11 Scope for Improvement  NICE (CG 36 2006) estimate up to 40% of AF patients whom warfarin indicated not receiving it = 166K patients nationally  Possibility of preventing 6,000 strokes and savings 4,000 lives pa

13. 12 Audit Benefits  High quality patient care  REDUCED STROKES, MORBIDITY & MORTALITY  Cost saving  Clinical audit  QOF points - Med Man Action (plus revised AF3 – 12 pts)

14. 13 Audit Key Objectives  All high stroke risk AF patients to be either prescribed warfarin or coded with reason why not.  All medium stroke risk AF patients to be considered for warfarin and coded with reason if not Rx.

15. 14 AF Management Issues  Increased identification of AF  Accurate diagnosis of AF  Stroke risk stratification  Effective management plan  Antithrombotic therapy as appropriate  Follow up and review