Atrial Fibrillation

Lord Rennard Excerpts

Tuesday 7th May 2019 Lords Chamber

[Lord Rennard (LD)]

My Lords, the noble Lord, Lord Black of Brentwood, is to be congratulated on securing this debate and on his personal tenacity in pursuing this issue through many other debates and questions and through the activities of the all-party parliamentary group. I have been pleased to take part in some of these, including the one to which he referred, in 2015, which focused on detection of AF. His Question today refers to the Menu of Preventative Interventions published by Public Health England in 2016. This communicated an ambition to increase optimal management of people with atrial fibrillation from 74% to 89% over the five years to 2021.

As the noble Lord said, AF is the root cause of one in five strokes, and people with the condition are five to six times more likely to suffer a stroke than those with a regular heartbeat. Aside from the human cost and many indirect costs, strokes directly cost the NHS more than £2.2 billion each year, but the risk of an AF-related stroke can be substantially reduced by providing effective anticoagulation therapy to prevent the formation of clots. Too often, however, AF remains underdiagnosed and undertreated. In 2014, NICE estimated that around 250,000 people in the UK have undiagnosed atrial fibrillation, and the King’s Fund says that a huge proportion of those who have been diagnosed with AF are not receiving the correct anticoagulation medicine to prevent stroke.

Better diagnosis and treatment could prevent around 7,000 strokes, prevent more than 2,000 people suffering severe disability and prevent 2,000 premature deaths each year. With an ageing population, AF prevalence is likely to grow, so why are we not identifying the condition and treating it as effectively as we might? Much of the problem is that there are significant gaps and inequalities in our health system, as shown by the rates of AF detection and access to therapies and treatment for stroke. Cardiovascular disease is one of the conditions most strongly associated with health inequalities, and if you live in England’s most deprived areas you are almost four times more likely to die prematurely than someone in the least deprived. Cardiovascular disease is also more common where a person is male, older, has a severe mental illness or is south Asian or African-Caribbean in ethnicity.

Action to address health inequalities, as proposed in the recent NHS Long Term Plan, is of course very welcome. The plan states:

“Early detection and treatment of CVD can help patients live longer, healthier lives. Too many people are still living with undetected, high-risk conditions such as high blood pressure, raised cholesterol, and atrial fibrillation”.


A new return on investment tool confirms that savings can be made from better identification and management of patients. This suggests that more than 14,000 heart attacks and strokes could be prevented each year through earlier identification, diagnosis and effective management of AF. However, we are not doing what we could because suboptimal treatment of AF is widespread, particularly through the prescribing of aspirin monotherapy.

The National Institute for Health and Care Excellence recommends that people with AF who are at risk of stroke should be offered either warfarin or a non-vitamin K oral anticoagulant, known as a NOAC. NICE also makes explicit that people with AF should not be prescribed aspirin on its own for preventing stroke, as the bleeding risks outweigh the clinical benefits. This is reiterated in the NICE AF quality standard, QS93:

“Adults with atrial fibrillation are not prescribed aspirin as monotherapy for stroke prevention”.


But some healthcare professionals still believe that aspirin is an effective alternative to other NICE-recommended therapies. This practice puts a significant number of patients at unnecessary increased risk of stroke. The most recent national audit for stroke reveals the extent of suboptimal treatment with aspirin monotherapy and the impact on patient outcomes. In 2017-18, approximately 2,400, or 14%, of AF-related stroke patients were being prescribed aspirin on its own when they were admitted to hospital. This issue can be addressed with better education for healthcare professionals, particularly in primary care, to prevent aspirin on its own being prescribed when new cases of AF are diagnosed. Just as importantly, local GP practices and the new primary care networks can take proactive steps to ensure that existing AF patients are appropriately anticoagulated by identifying and reviewing those currently prescribed aspirin alone for AF-stroke prevention, as a priority.

At a population health level, addressing inappropriate treatment in individuals whose clinical risk factors are suboptimally managed provides the opportunity for every health economy to improve AF-stroke prevention at scale in a short timeframe. This can be achieved by undertaking a systematic audit of primary care data to identify AF patients being treated with aspirin monotherapy, and offering them more effective long-term treatment with a NICE-approved anticoagulant therapy such as warfarin or a NOAC. The new NHS Long Term Plan included a commitment to support the creation of CVDprevent, a new national cardiovascular disease prevention audit, to support healthcare professionals in primary care to improve the identification and management of patients with high-risk CVD conditions, including AF. It is critical that this system incorporates metrics to systematically identify patients with AF currently treated with aspirin monotherapy.

There are a number of questions to consider. How close are we to having regular systematic audits in every GP practice? The guidance on risk assessment and stroke prevention for atrial fibrillation, known as the GRASP-AF tool, can help to identify people at risk who are not anticoagulated or who are suboptimally anticoagulated. How far is this tool being used to help GPs assess the risk of AF-related stroke and provide for effective management of AF in patients? Can the Minister tell us what new measures are being taken to ensure that new and existing patients with AF are not prescribed aspirin monotherapy for preventing stroke, in line with NICE clinical guidelines? In addition, can we know the timelines for implementing the CVDprevent primary care audit programme?

We look forward to hearing what steps are being taken to enable local NHS services to identify AF patients who are being suboptimally managed, and then supporting them to obtain the right treatment. We would like to know how local NHS clinical commissioning groups and providers are using the national audit for stroke to improve atrial fibrillation management. For example, what training is being made available to medical personnel and health staff, including pharmacists, to encourage pulse checks in routine check-ups, and in non-clinical settings, to detect AF?

Finally, I draw attention to how researchers at the University of Birmingham have developed two apps that help patients and clinicians manage atrial fibrillation more effectively. Funding for this research came in part from Horizon 2020, the EU framework programme for research and innovation. Will this kind of funding be guaranteed in future?