Atrial Fibrillation

Lord Colwyn Excerpts

Wednesday 4th November 2015 Lords Chamber

[Lord Colwyn (Con)]

My Lords, everything that could be said probably has been. I declare an interest as a member of both the AF APPG and the stroke APPG. We have meetings tomorrow, as we have heard. I also have personal experience of living with AF for many years.

Atrial fibrillation is the most common sustained cardiac arrhythmia and estimates suggest that its prevalence is increasing. If left untreated, atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and prevalence increases with age.

It has been suggested that AF can be detected by a simple pulse check. I have found that a pulse check should be verified with an oximeter. It is difficult to self-diagnose irregular cardiac rhythms that are often in excess of 150 beats per minute without the use of an oximeter. Perhaps that is what the GRASP machine is; I had not heard of it before. AF affects around 1 million people in the UK. Sometimes the condition does not cause any symptoms and a person with it may not be aware that their heart rate is irregular. It is important that AF is diagnosed so that medical practitioners can decide when active treatment is needed.

The aim of treatment is to prevent complications, particularly stroke, and to alleviate symptoms. Drug treatments include anticoagulants, to reduce the risk of stroke, and antiarrhythmics, to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non-pharmacological management includes electrical cardioversion, which may be used to shock the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the normal electrical impulses that cause atrial fibrillation. I have had both of these techniques.

There are also new updated guidelines that address several clinical areas in which new evidence has become available, including stroke and bleeding risk stratification, the role of new antithrombotic agents, and ablation strategies. The recommendations apply to adults—those aged 18 years or older—with atrial fibrillation, including paroxysmal, persistent and permanent atrial fibrillation, and atrial flutter. They do not apply to people with congenital heart disease precipitating atrial fibrillation.

Sadly, many people with AF are not diagnosed and many who have been diagnosed do not receive the anticoagulation treatment that they need. Between April 2014 and March 2015 only 38% of patients with diagnosed AF who were admitted to hospital with a stroke were being treated with anticoagulants. It has been estimated that as many as 700,000 people in the UK may have undiagnosed AF.

In recent years several anticoagulants, known collectively as non-vitamin K antagonists, have been recommended by NICE. Under the NHS constitution, patients should have access to the full range of treatment options recommended by NICE. However, data from NHS England reveal that only 11% of patients being prescribed anticoagulation are receiving these treatments. Improving access to the full range of anticoagulation therapies would bring benefits to patients and the NHS. The Government have estimated that up to 7,100 AF-related strokes could be prevented annually if everyone with AF were appropriately managed.

Since 2012 four novel oral anticoagulants have been recommended by NICE as both clinically effective and cost-effective for the prevention of strokes in patients with AF. These treatments should now be available to all patients whose doctors wish to prescribe them. Their use is increasing, but it is lower than expected. All healthcare professionals caring for people on anticoagulation therapy should be familiar with the full range of treatment options. Despite having a NICE recommendation as being clinically effective and cost-effective, many GPs appear to lack confidence in the use of NOACs to prevent AF-related strokes.