Atrial Fibrillation

Viscount Craigavon Excerpts

Tuesday 7th May 2019 Lords Chamber

[Viscount Craigavon (CB)]

My Lords, we should be grateful to the noble Lord, Lord Black of Brentwood, for tabling this important subject for debate and for his tour d’horizon of the facts and circumstances of AF. I have chosen to focus more on the Question, which may be a mistake. I have been a member of the All-Party Parliamentary Group on Atrial Fibrillation for some time, and have tried to support its good work, in which it has the excellent outside help of the AFA—the AF Association.

The direct Question asked by the noble Lord, Lord Black, has been rather overtaken by a more up-to-date report published in February this year, more narrowly focused on CVD—cardiovascular disease—rather than many preventive interventions in the whole of the NHS, which the earlier report covered. That earlier report by Public Health England in 2016 gave a five-year plan to come up with the figure of 89% by 2021. The key words in the Question are “known … patients”, as there are estimated to be an additional huge number, about 300,000 people, who have this condition but are undiagnosed and unaware of it but who nevertheless suffer from it in varying degrees.

As to what is meant by the phrase “appropriate treatment”, if the underlying problem with AF is an irregular heartbeat or activity, this might lead to clots or strokes. When people are offered anticoagulants, that may usefully ameliorate the symptoms, but it is not strictly treating the underlying heart condition itself. When we are talking about treating 89% of patients, that is not treating the underlying cause in the heart, which can be very difficult, but largely dealing with the symptoms, which is nevertheless useful and desirable.

The more recent report, in February, again emanating from Public Health England, focusing solely on CVD, has chosen to launch a new 10-year prediction or ambition, ending in 2029. Again, this covers only known patients, but is obviously aiming also to reduce the number of those unaware of their condition. It is nevertheless useful to have the Minister here to answer how the 2016 prediction for 2019 is presently going and whether the figure of 89% for 2021 is realistic. In all these percentage predictions, it can be asked how useful or valuable it is to create these sorts of targets, especially some time ahead, with so many variables likely to intervene.

One might also ask by what authority such ambitions are arrived at. Like the sustainable development goals, successors to the millennium development goals, many of which failed to reach their expectations, I believe it is better to have common benchmarks, against which some sort of progress can be measured. However, as with the current climate change debate, one can be slightly sceptical about predictions the further away in time they are laid out. I am grateful that we have these Public Health England reports and predictions, and I do not want to seem to be nit-picking about the percentages, all of which I have taken from them. However, the target or ambition in the 2016 report, as in the Question, is that by 2021 89% of known patients should be on appropriate treatment for AF; whereas in the latest report, in February this year, the 10-year target ambition from now—apparently 84%—to 2029 is going to be only 1% higher, at 90%. I realise that in many things the last few percentage points are sometimes the most difficult to achieve, and it may be that the latest report has wisely resisted the temptation to be too optimistic.

To explain where this comes from, I will quote the report itself:

“Progress has already been made”—


to 84%—

“and it has therefore been agreed that the ambition for optimally managing AF should be 90%. There is clinical consensus that a treatment ambition of 90% is appropriate and achievable”.

I emphasise the words “optimally managing AF”. As I said earlier, the Minister might be able to throw some light on these intentions.

As I also said earlier, all the percentages I have quoted so far relate to known cases of AF, but the report I mentioned also deals with the percentages of detection. As the noble Lord, Lord Black, mentioned, that is what percentages of all cases are known and have been identified. That is obviously difficult to estimate, but I earlier gave the round figure of 300,000 for those not detected, which in the 10-year report relates to a starting figure for detection of 79%. That is set against the target in 10 years—for 2029—of 85%. Again, whatever the figure might be, that size of the unknown is very worrying, especially as everyone agrees that AF can be readily diagnosed.

Leaving percentages behind for now, I shall continue on the latest report by Public Health England, of February 2019, on CVD. AF is only one of three aspects of CVD it covers, the others being blood pressure and cholesterol. It is encouraging that this report also addresses some stark health inequalities, committing to publishing data highlighting high-risk conditions and setting goals in future to remedy these. It also usefully raises the aspect of return on investment, which is not just financial but includes lives saved and lived. It also helpfully reminds us that the present direct annual cost to the NHS of CVD is £7.4 billion, and that the wider, non-healthcare costs are at least double that, at £15.8 billion.

I shall focus the rest of my speech on AF amelioration and therapies, where changes have been frustratingly slow. There is a general need to make the public and clinicians aware of and understand the particular connection between AF and prevention of strokes. It is widely accepted that aspirin has no effect on AF, but it is still widely prescribed for known AF patients. That figure might be as high as 20%, when there are so many improved remedies available today. There is a high percentage of patients who have suffered strokes and are known to be AF patients but who are not receiving any effective anticoagulants.

One therapy that can be effective, if properly given, is warfarin, but there are often shortcomings in administering this. While I realise that not all therapies are suitable for everyone, there are the recent additional medicines called DOACs, also referred to as NOACs, which, while they may be more costly, provide much simpler and successful outcomes for most AF patients. I realise that there is something called clinical independence, and that clinicians cannot be forced to prescribe what others might think best, but this is a long-term matter of educating and informing both patients and clinicians. This will continue to be a valuable and worthy process, but at the same time it is frustratingly slow. If anyone has seen the effects of a stroke and thought, often correctly, that it could have been avoided, I hope they might support efforts to make knowledge about AF a more important priority in our health service.