By Sharon Gordon, Pharmacist Consultant Anticoagulation & Faculty Fellow of The Royal Pharmaceutical Society
Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia affecting 1-2% of the UK population. AF is affecting approximately 10% of the population over 75 years old and 18% of those over 85 years old. It is a predominant cause of stroke and a serious concern in in our aging population. Clinical outcomes in terms of increased disability are considerably worse for AF-associated stroke and mortality from stroke is doubled in patients with AF.
Around 50% of patients admitted to hospital with a stroke had been diagnosed with AF and were either not treated with an anticoagulant or were being treated with aspirin or other antiplatelet which is insufficient to protect against stroke.
In Wessex alone, there are 39,829 high risk patients with AF not currently on anticoagulation. Finding and treating these patients optimally could lead to 1076 fewer strokes and 358 fewer deaths, leading to £19.5 million hospital admissions costs avoided. This is not dissimilar to any region in England. Finding and caring for these patients is the responsibility of every health professional.
Signs and Symptoms
The biggest challenge with managing and caring for patients with AF is that many do not feel the arrhythmia and may be symptom free, but of course, not free of the risk of stroke.
Other patients may experience:
• Breathlessness, often as the first symptom. At rest or on exertion.
So What is Going Wrong?
Early diagnosis and correct treatment is crucial for managing the risk of stroke.
There are problems across the pathway and subsequent failures to detect patients with AF. There are failures in initiating joined up discussions and treatment plans for new patients, as well as managing the condition so patients stay safe on anticoagulation. Compounding this problem is a huge backlog of patients who are on GP registers with known AF and on incorrect or no treatment.
What is the Role of Pharmacists?
There is a role for our profession to demonstrate their crucial skills in the care of patients on anticoagulation and with AF.
Secondary care pharmacists should be reviewing aspirin in all patients admitted to understand the reasons for treatment and advising on alternatives if the patient has AF. Patients discharged must have proper counselling on their anticoagulation and referral to community pharmacy for follow up.
Practice pharmacists could utilize their analytical skills supporting GP practices to audit GP registers and generate lists of patients to review.
Community Pharmacists can have a crucial role in early detection of AF. There are many mobile ECG devices available to offer opportunistic testing for AF. One such device is called AliveCor. This device is smaller than a credit card and highly accurate! In 30 seconds it takes a trace which can then be emailed to the patient (or GP or consultant).
The second key focus for the community pharmacists should be the support with medicine adherence and safety advice, through the New Medicine Service. The community pharmacist is ideally placed to support this discussion with patients but data from the Medicines Optimisation dashboard suggests that NMS discussions for aspirin and anticoagulation do not happen as frequently as they should.
In Wessex we are testing a scheme with local GPs where they provide a card to direct patients to the community pharmacy.
Have you thought about these things in your area? How can you adapt your role to support this patient group better?