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 6.71
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