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Presentation on theme: "AF and NOACs An UPDATE JULY 2014"— Presentation transcript:

1 AF and NOACs An UPDATE JULY 2014
Helen Williams Consultant Pharmacist for CV Disease South London

2 The prevalence of AF in 80-89 year olds is as high as 9%.1
Most people seem to agree that the prevalence figures are under-reported due to the asymptomatic nature of AF. 2 As with many conditions, the more you look, the more you find. References: Kannel WB et al. Prevalence, Incidence, Prognosis, and Predisposing Conditions for Atrial Fibrillation: Population-Based Estimates. The American Journal of Cardiology. 1998; 82 NHS Improvement. June Available at accessed April 2010.

3 % of strokes attributable to AF
AF and stroke risk % of strokes attributable to AF AF is the leading - and most preventable - cause of embolic stroke Risk increases with  age Without preventive treatment, approximately 1 in 20 patients (5%) with AF will have a stroke each year % HW Age (years) Kannel WB et al. Am J Cardiol 1998; 82 (8A): 2N–9N.


5 NICE Guidance 2014

6 NICE Priorities (CG180) Personalised package of care
Assessment of stroke and bleeding risk Use of CHA2DS2-VASc and HASBLED Anticoagulation with warfarin or a NOAC Stop using aspirin for stroke prevention in AF Rate and rhythm control Specialist referral and interventions where first line options fail to manage symptoms adequately

7 CHA2DS2-VASc Annual stroke rate, % Score 1 1.3 2 2.2 3 3.2 4 4.0 5 6.7
1 1.3 2 2.2 3 3.2 4 4.0 5 6.7 6 9.8 7 9.6 8 9 15.2 Congestive heart failure/ 1 LV dysfunction Hypertension Age  Diabetes mellitus 1 Stroke/TIA/TE Vascular disease (CAD, CArD, PAD) Age Sex category (female) 1 Score 0 – 9 Validated in 1084 NVAF patients not on OAC with known TE status at 1 year in Euro Heart Survey OR for stroke if: Female: 2.53 (1.08 – 5.92), p=0.029; Vascular disease: 2.27 (0.94 – 5.46), p=0.063 7

8 Assessment of risk of bleeding - HAS-BLED
Score Bleeds per 100 patient-years 1.13 1 1.02 2 1.88 3 3.74 4 8.70 Hypertension (current) Abnormal renal/liver function 1/2 Stroke Bleeding Labile INR Elderly (age > 65 years) Drugs or alcohol /2 Low Inter- mediate High Score 0 – 9 c-statistic 0.72 Validated in 3978 NVAF patients with known TE status at 1 year in Euro Heart Survey c-statistic 0.72 (similar to HEMORR2HAGES) 0.91 vs 0.85 for patients on ASA or no therapy Pisters R, et al. Chest 2010;138: 8 8

9 Myths and Misconceptions…
Aspirin is as effective as oral anticoagulation Aspirin is safer than oral anticoagulation Falls are a C/I to anticoagulant therapy Prior GI bleeds are a C/I to anticoagulation

10 So, where are we now? Up to 15% of patients cannot take warfarin due to allergy, contraindication or inability to manage the monitoring requirements. Up to 40% are not controlled within therapeutic range on warfarin Up to 45% with atrial fibrillation at high stroke risk are not currently anticoagulated – see QOF!

11 Where are we now? ~4% uptake of NOACs in the UK market
Data on file: Bristol-Myers Squibb Pharmaceuticals Limited DOT = Days on therapy

12 NOACs: Prioritizing Patients
…. And return on investment? Patients unable to take warfarin due to allergies / CI and patients unable to comply with monitoring of warfarin (n=207) HIGH PRIORITY = 7 strokes prevented £166k = strokes prevented £141 -£282k Patients out of range (n =252 – 501) MEDIUM PRIORITY = strokes prevented £505 - £1,010k Patients on aspirin or nothing (n= ) = 3 – 5 strokes prevented £147k New Patients (n=261) LOWER PRIORITY Patients currently stable on warfarin (n=756 – 1005) £425- £565k Plus... up to £915k for currently undetected AF What about costs?* * Annual costs based on a CCG in South London, population 300k (prevalence = 0.9%) 12

13 Novel oral anticoagulants SW London Positioning 2014/15
An alternative to warfarin for SPAF in patients with CHADS2 ≥ 1 who: have a warfarin allergy, warfarin specific-contraindication or are unable to tolerate warfarin therapy are unable to comply with the specific monitoring requirements of warfarin are unable to achieve a satisfactory INR after an adequate trial of warfarin have had an ischaemic stroke whilst stable on warfarin therapy are unwilling to take warfarin after a full discussions of the risks and benefits

14 SWL Positioning 2014/15 Warfarin is a suitable first-line option for many patients Initiation by clinicians with ‘expertise in initiating anticoagulation’ Initiating clinician responsible for at least first 3 months of therapy: Address side effects Emphasise importance of adherence Transfer to patients own GP when ‘stable’ and in line with approved indications

15 Prescribing NOACs Check indication – AF, VTE treatment or prophylaxis
Check patient age – dose adjustment at 80 years with dabigatran Check renal function Not just eGFR Calculate creatinine clearance Check for adverse effects Dabigatran dyspepsia in up to 10% patients Rivaroxaban / apixaban: headache / dizziness Check adherence No monitoring of bloods (except annual renal function) therefore possible increased risk of non-adherence over time


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