Patients with AF who are most at risk of stroke are typically treated with drugs, known as anticoagulants, to slow down the blood clotting process. These drugs help to prevent blood clots from forming in the heart and therefore decrease the risk of future stroke. More information on stroke prevention in atrial fibrillation is available here.
The SLCSN is working with organisations to improve the identification and management of AF through initiatives such as the NHS Health Check programme and the GRASP-AF tool. The use of GRASP-AF (a tool available for use with all GP clinical systems in England) will ensure appropriate stroke risk assessment for anticoagulant treatment with the aim of increasing the rate of anticoagulant prescribing for patients at moderate and high risk of a stroke.
Warfarin is the most commonly prescribed anticoagulant drug, and is very effective at reducing the risk of stroke in patients with AF. Warfarin requires regular monitoring of a patient's international normalised ratio (INR) and careful tailoring of the dose to the individual patient. Warfarin levels can be affected by such things as diet, alcohol or interacting drugs. Therefore, in some patients, it can be difficult to control.
Novel oral anticoagulants (NOACs)
Two new oral anticoagulants were licensed in 2011 for stroke prevention in AF. As these drugs have a more predictable anticoagulant effect, they do not require regular monitoring of INR in anticoagulant clinics.
- Apixaban, a third agent, a factor Xa inhibitor, was licensed February 2013. It is prescribed at a 5mg dose twice daily.
- Dabigatran, a direct thrombin inhibitor, is prescribed at a dose of 110mg or 150mg twice daily. NICE have endorsed the use of dabigatran as an option for stroke prevention in AF.
- Rivaroxaban, a factor Xa inhibitor, is prescribed at a dose of 20mg once daily. NICE recommended rivaroxaban as an option for treatment in guidance published in May 2012
The introduction of these new agents will require significant pathway redesign and realignment of anticoagulant services in order to offset the additional cost of these drugs. The SLCSN is working with hospital and primary care clinicians to facilitate a phased introduction of these drugs alongside development of guidance and advice for prescribers to ensure their safe use.
This page will be updated as new information becomes available.
- SLCSN position statement on NOACs - This position statement is intended to support the implementation of NICE guidance for NOACs across South London and identify which patient groups should be prioritised for treatment.
- Suggested treatment pathway for anticoagulation for stroke prevention in atrial fibrillation (SPAF)
- SLCSN guidance on the use of Apixaban for stroke prevention in AF
- Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation - NICE guidance TA275(February 2013)
- SLCSN guidance on the use of dabigatran for stroke prevention in AF
- SLCSN patient information leaflet (April 2012)
- Click here to open a version of the SLCSN patient leaflet formatted for printing
- Dabigatran etexilate for preventing stroke and embolism in people with atrial fibrillation - full NICE guidance (March 2012)
- Atrial fibrillation - dabigatran etexilate: understanding NICE guidance - patient version of guidance from NICE (March 2012)
- SLCSN guidance on the use of rivaroxaban for stroke prevention
- Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation - full NICE guidance (May 2012)
- Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation - patient version of guidance from NICE (May 2012)
The SLCSN Prescribing Forum is headed by Helen Williams, clinical chair. Questions may be directed to sou-pct.SLCSNprescribing@nhs.net.