BMJ 2014;348:g313 doi: 10.1136/bmj.g313 (Published 21 January 2014)

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NEWS New anticoagulants should be considered for atrial fibrillation, says NICE Ingrid Torjesen London

GPs should no longer automatically prescribe warfarin as the first line treatment for atrial fibrillation but weight up its risks and benefits against those of the newer anticoagulants, the UK National Institute for Health and Care Excellence (NICE) has said in a review of its guidance on managing the condition.

NICE’s draft update of its guideline on atrial fibrillation also proposes other wide ranging changes to management, including GP’s routine use of risk calculation scores for stroke and bleeding when assessing and monitoring patients; rate rather than rhythm control as the first line approach; and wider use of non-pharmacological techniques such as electrical cardioversion and ablation.

Patients with atrial fibrillation have a fivefold increased risk of stroke, so preventing stroke is a major treatment goal, the guideline says. NICE’s draft update recommends that GPs routinely use the CHA2DS2-VASc score to assess the risk of stroke in patients with atrial fibrillation.1 Once their risk of bleeding has been taken into account, anticoagulation should be offered to patients with a CHA2DS2-VASc score of ≥2 and considered for men with a score of ≥1. Research shows that only 55% of patients with atrial fibrillation who fulfil the current criteria for anticoagulation, as laid out in NICE’s original 2006 guideline, are receiving the drugs.2

The draft guideline says that GPs should use the HAS-BLED score to assess the risk of bleeding when initiating anticoagulation treatment and when monitoring patients. NICE also brings together recommendations from its technology appraisals of dronedarone, dabigatran, rivaroxaban, and apixaban to reaffirm that these new anticoagulants should be considered to be on a par with vitamin K antagonists (warfarin) as potential treatments. Although aspirin can also be given for its antithrombotic effects, the draft guideline adds that it should no longer be offered as monotherapy solely for stroke prevention in patients with atrial fibrillation. In another major change to its 2006 recommendations, which recommended rhythm control for some patients, NICE’s draft update says that rate control should be the first line strategy for all patients with atrial fibrillation. The guideline development group acknowledged that rate and rhythm control are not

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necessarily alternative strategies and said that, although rate control should be considered first line, it should not necessarily be discontinued if clinicians progress to a rhythm control strategy.3 Rhythm control should be reserved for patients, with or without continuing symptoms, if they have atrial fibrillation with a reversible cause, heart failure thought to be primarily caused by atrial fibrillation, or new onset atrial fibrillation.

NICE also says that patients who need cardioversion for atrial fibrillation that has persisted for longer than 48 hours should be offered electrical rather than pharmacological cardioversion. Furthermore, if drug treatment has failed to control symptoms or is unsuitable, patients with paroxysmal atrial fibrillation should be offered left atrial catheter ablation, while those with persistent atrial fibrillation should be considered for left atrial surgical or catheter ablation.

Mark Baker, director of NICE’s Centre for Clinical Practice, said, “People with atrial fibrillation have a possible fivefold increased risk of stroke. Therefore it’s important that people with atrial fibrillation are diagnosed properly and have their condition managed effectively in order to reduce the significant risk of stroke and prevent deterioration in their quality of life. “This updated draft guideline reflects important new evidence about the best ways to treat the condition, including the use of the new generation of oral anticoagulants and ablation strategies, as well as the use of risk calculators to guide treatment decisions.”

The consultation on the draft guideline is open until 26 February 2014. 1 2 3

National Institute for Health and Clinical Excellence. Atrial fibrillation: the management of atrial fibrillation. NICE guideline (draft for consultation). Jan 2014. www.nice.org.uk/ nicemedia/live/13590/66265/66265.pdf. Cowan C, Healicon R, Robson I, Long WR, Barrett J, Fay M, et al. The use of anticoagulants in the management of atrial fibrillation among general practices in England. Heart 2013;99:1166-72. National Clinical Guideline Centre. Atrial fibrillation: the management of atrial fibrillation. Clinical guideline: methods, evidence and recommendations (draft for consultation). Jan 2014. www.nice.org.uk/nicemedia/live/13590/66267/66267.pdf.

Cite this as: BMJ 2014;348:g313 © BMJ Publishing Group Ltd 2014

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BMJ 2014;348:g313 doi: 10.1136/bmj.g313 (Published 21 January 2014)

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New anticoagulants should be considered for atrial fibrillation, says NICE.

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