Allyson Arnold gives an overview on everything pharmacists need to know about this common cardiovascular condition
Key learning points
- The prevalence of AF is expected to significantly with an ageing population
- Early detection can prevent medical interventions and hospital admissions
- Pharmacists are well placed to spot signs of deterioration in patients they see regularly
Atrial fibrillation (AF) is the most common sustained adult cardiac arrhythmia. Normally, the heart’s natural pacemaker sends out a regular electrical impulse that travels through the heart and makes it beat in time. But in people with AF, extra impulses fire off randomly from different points causing the top of the heart to twitch, or fibrillate.
The result is often an irregular and sometimes very fast pulse. AF increases the risk of a blood clot forming in the heart, which can travel to the brain and cause a stroke. The chances of having AF increase with age, with condition affecting more than 6% of people over the age of 65. People with some conditions are more likely to develop AF. These include diseases of the heart such as coronary heart disease, heart failure, heart valve disease and high blood pressure, and other causes such as overactive thyroid, lung cancers and chest infections like pneumonia and alcohol or drug misuse.
The AF challenge
In the UK there are currently over 1.2 million people diagnosed with AF and almost a quarter of people with AF are undiagnosed. According to Public Health England, around 14,220 strokes in England could be avoided over three years if everyone with AF was diagnosed and received appropriate anticoagulation therapy. Not only could optimising AF treatment prevent a staggering number of strokes; this could also save the NHS £240 million pounds.
AF is also costly in terms of increased mortality, morbidity and reduced quality of life, increasing the risks of a number of associated cardiovascular conditions including stroke, heart failure and vascular dementia. Audits across the UK confirm that the use of anticoagulation to reduce the risk of AF related stroke is underutilised [i]. As many as half of people with known AF who suffer a stroke are not treated with anticoagulants before the event. [ii]
With a growing ageing population, the prevalence of AF is expected to rise significantly due to the increasing incidence and prevalence of those living longer with associated long term conditions [iii]. Those living with AF have a five-fold increase in their stroke risk [iv] , so to reduce the likelihood of AF leading to a stroke, it is imperative to ensure that individuals receive appropriate treatment.
Detecting and diagnosing Atrial Fibrillation
The most common presenting symptom is palpitations; people experiencing palpitations often say it feels as if their heart is jumping all over the place. Other symptoms include breathlessness, dizziness, tiredness and syncope, although many people may have no symptoms and without testing are unaware of their level of risk.
An irregular pulse is a sign that someone might have AF so using opportunistic pulse checks in those over the age of 65 can be much more effective in the detection of AF, rather than relying on people to present with symptoms.
Advances in technology have meant that access to mobile single lead ECG monitors will allow individuals to detect, monitor and manage heart arrhythmias with automatic analysis. Currently, the AliveCor Kardia Mobile ECG is being rolled out to 33 NHS organisations, including GP practices and acute trusts through the NHS Innovation Accelerator programme, enabling the recording of 1.3 million ECGs across the UK. This includes a trial within Care City NHS Test Bed in North-East London, where the device is being used within community pharmacies.
At what point should patients be referred and to whom?
People will often seek advice from a pharmacy and this is an ideal opportunity for the pharmacist to detect early warning signs of what could potentially be AF. Early detection and timely referral can make a significant difference. Pharmacists see people regularly and are able to detect signs and symptoms of deterioration. If a patient has symptoms of AF, it is important to informally refer them to their GP as soon as possible, however some patients are opportunistically diagnosed when undergoing monitoring for other conditions. An irregular radial pulse may raise suspicion of AF, but diagnosis can only be made from a 12-lead ECG. Patients with irregular AF may require ECG monitoring for 24 hours to determine diagnosis.
There are some barriers within the current primary care referral system and encouraging more direct referrals to and from community pharmacists may alleviate some of the pressures on primary care, especially in patients with AF. Early detection with appropriate information, support and simple lifestyle changes could prevent significant medical interventions and hospital admissions in the longer term.
What advice can community pharmacists give to AF patients?
Community pharmacists can provide patients with information on AF, including signposting them to patients resources. The British Heart Foundation have patient resources on AF (www.bhf.org.uk/publications) as well as a nurse Helpline (0300 330 3311) where patients can get more information.
What other support can they give?
Community Pharmacists are well positioned to provide extra support for those with AF and more opportunities for simple screening could be explored as part of preventative approaches to healthcare. They are able to provide appropriate information and support through signposting or having leaflets readily available in their pharmacies. Pharmacists can also provide simple lifestyle advice, such as healthy eating, physical activity, losing weight and stopping smoking.
If a pharmacy offers a Medicines Use Review (MUR), this can be an ideal time to speak with patients about the medication they have been prescribed if they have known AF, and help improve adherence for those who are prescribed medication for their AF. Therapy adherence plays an important role in managing AF, as inconsistent anticoagulation therapy may be associated with a worse outcome and a higher risk of stroke-associated disability.
The increasing role of pharmacists in AF detection and management
It is clear that mobilising the wider primary care system and organising services differently to support general practice and ensure patients get proven treatments will be the key to improving the detection and management of AF. Pharmacists can play a key role in delivering improved quality of care. They can do this through opportunistic case finding for AF, following NICE guidance to review the use of aspirin (aspirin for stroke prophylaxis in AF is now not recommended), ensure anticoagulation is discussed with the patient and promote the discussion about the choice of anticoagulant.
In England, examples of health care models using pharmacists include:
- In Dudley, practice based pharmacists took over routine diagnosis and management of high blood pressure. In one year 27,800 new patients were detected with undiagnosed hypertension, and there was a substantial increase in numbers controlled to the NICE target of 140/90.
- In West Hampshire a mix of GP education, diagnostic devices for AF and pharmacist-run anticoagulation services resulted in an estimated 52 strokes being averted in 20 months.
- In Lambeth and Southwark, pharmacists were commissioned to manage blood pressure and AF. Over 15 months, an estimated 45 strokes were averted.
- In North West London, an outreach scheme was developed involving ten community pharmacies in Hillingdon, London and the Royal Brompton and Harefield NHS Foundation Trust’s specialist arrhythmia care team, working together to refer and treat patients. In the six month-long data collection phase of the project, the team tested 600 patients for AF, and there are plans to roll it out to reach 3,000 patients across 30 pharmacies.
Pharmacists are a much needed and valued workforce that can improve public/patient understanding and deliver personalised packages of care, including stroke awareness, signposting and prompt referral for those with symptomatic AF. Pharmacists can also provide continuity of care as well as essential patient education support (as recommended by NICE) and ensure that individuals with AF are supported to understand cause, effects and possible complications of AF. Improving the understanding of these issues is pivotal in motivating individuals to engage with evidence-based treatment, which is of particular relevance for the 30% of people with AF who are asymptomatic.
There is currently a spotlight on the scale of the opportunity to do better in secondary prevention of CVD. With newly formed partnerships and new models of care using a highly skilled and engaged pharmacy workforce, a more creative and joined up environment will emerge in order to prevent CVD in the longer term. By doing things differently and at scale across regions, large numbers of strokes and heart attacks can be prevented in the relatively short term and substantial financial savings will be delivered.
Jenny Hargrave, Director of Innovation in Health and Wellbeing at the British Heart Foundation said: ‘Pharmacists are becoming an increasingly significant provider of healthcare advice and support for people living with heart and circulatory disease.
‘The BHF is working with leaders across the health system, harnessing research evidence and NICE guidance to reduce variation and optimise treatment of AF. We recognise that there is an increasing role for pharmacists to help patients to better manage their condition, supporting patients with shared decision making, monitoring and medication adherence. We are encouraged to see increasing community pharmacist involvement in this important activity.’
Allyson Arnold is health services engagement lead at the British Heart Foundation
[i] National Clinical Guideline Centre. Atrial Fibrillation: the management of atrial fibrillation. Clinical guideline. Methods, evidence and recommendations. June 2014. Commissioned by the National Institute for Health and Care Excellence (full version)
[iii] Kannel WB, Wolf PA, Benhamin EJ et al. Prevalence, incidence, prognosis and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cariol 1998; 82:2N-9N
[iv] The office of Health Economics. Estimating the direct costs of atrial fibrillation to the NHS in the constituent countries of the UK and at SHA level in England, 2008. London: The office of Health Economics; 2009.