1. THE NATIONAL ANTICOAGULATION INITIATIVE
Dr Andy Hughes
Consultant Community Haematologist
South West Essex Community Services
and
North East London Foundation Trust

2. ~ 12,500 AF-related strokes/year in the UK
High economic cost ~£600 million direct cost to NHS
£800+million in “indirect” costs
Incidence of AF set to double from one to two million by 2050

3. AF related strokes are bad!
25% mortality at 30 days.
Significant disability.
“A fate worse than death”
 burden on:
Carers
Family
Society
Health & social services

4. AF also associated with
Increased incidence of silent cerebral infarcts
15% in AF patients with no prior h/o stroke
Ezekowitz et al Circulation. 92(8):2178.
Increased incidence of dementia
Bunch et al Heart Rhythm. 7(4):433.

5. AF STROKES ARE PREVENTABLE
65% reduction in stroke
20% reduction in stroke
Similar bleeding risk to Warfarin

6. GRASP-AF Guidance on Risk Assessment and Stroke Prevention for AF
Total
Patients
with AF
with C2
>2
C2 >2 on
OAC
C2 >2 not on
ASA
C2 >2
No anti-
thrombotic
B/Wood
- total
76,511
1,480
911
532
381
293 88
- %
1.9%
61.5%
58%
42%
32%
10%
National data*
1.77%
57.5%
56%
43.6%
35%
8.7%
*as of Jan 2013
C2 = CHADS2 score
OAC = oral anticoagulant
ASA = Aspirin
2 main risk factors with C2
Hypertension
Age >75

7. WHAT’S MORE…..
Patients with AF & a previous stroke admitted with 2nd stroke
57% on a VKA.
Of these only1/3rd have therapeutic INRs.
25% are only on an antiplatelet agent.
15% are not on any anti-thrombotic.

8. Key issues in commissioning anticoagulation therapy NICE May 2013.
Variation in the quality and safety of anticoagulation therapy across the country
Variation across the country in the activities of anticoagulation services, because there is no standard service model or definition of an anticoagulation service
A large proportion of people with AF are currently not receiving anticoagulation therapy in line with NICE guidance.

9. NATIONAL ANTICOAGULATION INITIATIVE
CREATING A SYSTEM OF CARE
SYSTEM
Defines the outcome to be delivered to patients
NETWORK
Determines who delivers care to the patients
PATHWAY
Describes how the care is delivered

10. The National Anticoagulation Initiative System
Common aim – stroke reduction in individuals with AF
Shared:
Objectives
Criteria
Standards
Individual local service pathways
Annual report on a standardised template published on The Initiatives website* *

11. OBJECTIVES
Promote stroke risk assessment of all known AF patients using CHADS2 (or CHADS-VASc).
Increase the percentage of patients with CHADS2 scores of >2 on an OAC.
Decrease the percentage of patients on APT.
Measure the efficacy and safety of anticoagulation provided:
Clinic TTR
Percentage of patients with a TTR of >60%
Critical INRs (<1.5 and >5.0)
Adverse events (bleeding or thrombosis)

12. ADDITIONAL OBJECTIVES
1/3rd of individuals with AF are asymptomatic
Case finding with opportunistic pulse taking (“Just a minute”)
Service Integration AF

13. The National Initiative in Brentwood
Nurse-led anticoagulant clinic
~850 active patients
Nine practices
Population ~76,000
~1500 known AF patients

14. “Houston, we have a problem…”
Doctors fear bleeding:
Patients not put onto Warfarin.
Undertreated.
EDUCATION
Patients fear stroke.

15. Education, education, education………
Educating colleagues and patients about AF is not just about sharing knowledge but about changing behaviour.
“Knowledge is the enemy of disease.”

16. How can we drive this forward?
Initiative in preventing stroke & vascular dementia
The National Anticoagulation Initiative is part of one of the working themes
Public Health can be an important driver of:
CCGs
GPs
Support of PHE will be important for the success of The Initiative.
NHS Health Check implementation review and action plan
July 2013

17. THE NATIONAL INITIATIVE
Brought together a group of innovators from different parts of the country
Shared aim and agreed objectives
Promote best practice
Simple measurements of success, quality and safety
Scalable national anticoagulation and stroke prevention programme
Aim for national coverage within 5 years
Reduce the high economic cost of AF-related stroke
Reduce the burden on carers, family, society
Reduce the demands on health and social services