The Active Practice Link (APL) tools are practice facing clinical tools that show in the GP practice, the characteristics of people with a particular condition - atrial fibrillation, heart failure, hypoglycaemic risk.
APL - AF Tool
The APL-AF tool shows patients with atrial fibrillation on aspirin monotherapy and age, CHADSVASC, calculates their HASBLED score and their social situation (housebound) and comorbidities like palliative care, dementia or diabetes/COPD/CVD. It illustrates control of other risk factors like statin use and BP control and rapidly identifies high risk patients with AF who are not taking anticoagulants. It provides a snapshot of any patient on the practice AF register and can be used to target and recall people where management could be improved.
The tool is an aid to clinical decision making and does not replace the need for clinical judgment in each individual clinical circumstance.
How do I get hold of the APL - AF tool?
Impact of Quality Improvement in Atrial Fibrillation in three CCGs 2013 to 2016
Figure-1 below shows the improvement in anticoagulation in three CCGs City & Hackney, Newham and Tower Hamlets.
Please read our latest guidelines Clinical Guidance for more information.
- Is Aspirin classified as an appropriate medication for patients with AF if the patient is contraindicated to Warfarin?
Aspirin is not classed as an appropriate medication for patients with Atrial Fibrillation because there is no evidence it prevents strokes in these patients.
It is highly unlikely a patient is contra-indicated to Warfarin, all NOACS and any other anticoagulant. If this is the case then they should be discussed with a haematologist who might recommend Aspirin rather than nothing.
- What should a practice do for the patients with Atrial Fibrillation who are on no medication?
Around 15% of AF patients will not be on warfarin/NOAC or antiplatelet medication. It is important to check these patients, but it is often the case that there are other good reasons why these patients are not on anticoagulation. For example, previous major bleed or the patient is dying.
Some patients who have had previous major bleeds might be appropriate for atrial appendage device surgery and a specialist in AF/haematologist could advise.
- Are there any patients who should be on an Anti-Coagulant and Aspirin?
There are a very small number of patients who might be on both drugs due to cardiac surgery. e.g. Patient may have a cardiac stent or other complex cardiac surgery – these should have been reviewed at least annually by a cardiologist to check this is still necessary.
- For patients who have both CHD and AF, should they be on aspirin or warfarin?
It is important to reduce risk of stroke as well as MI and Warfarin is drug of choice as patient has AF. If you are unsure what to prescribe then speak to the Haematologist or Cardiologist.
- QOF target is for people with CHADSVASC score greater than or equal to 2 should be on anticoagulant treatment, what about lower score?
Any patients aged 65 or over will have a score of 1 or more and should be on an anticoagulant.
Both men and women under 65 years with no other risk factors – do not require anticoagulation (despite the fact that Female =1 in the scoring system). If men or women are under 65 with any risk factor they should be on an anticoagulant.
- What about patients with heart valve disease?
They automatically qualify for anticoagulation regardless of their CHADVASC and in general are managed by haematology clinics.
- What about the HASBLED score?
If score >=3 then person is at higher risk of bleeding. However this is not a contraindication to anticoagulation as many of the risk factors for bleeding are the same as risk factors for stroke. The HASBLED score signals a need for caution and perhaps discussion of HASBLED 3 or more with a haematologist.
- What is drug of first choice, Warfarin or NOAC?
Warfarin is taken once daily and stays in system longer than NOAC, so if patient occasionally forgets to take medication, it may be a better option. Also Warfarin is rapidly reversible. Patients on warfarin have regular check blood tests which may improve adherence. Some patients on warfarin have difficulty achieving control even though they take their medicine – NOACs may be a better option for these people.
There are fewer drug interactions with NOACs which are at least as effective in preventing stroke. Intracranial haemorrhage may be less of a risk with NOACs but bleeding overall is similar.
With NOACs there is no need for regular blood tests and medicines may be taken once or twice a day depending on the drug. Lower doses are required for older frail people and those with CKD.
Patient choice is an important factor to consider.
About 20% of patients in trials with both warfarin and NOACs discontinue their medication – adherence is a serious issue with any anticoagulant
- Why is there data on NSAIDs in the data sheet on the tool?
Patients should not take NSAIDs if they have Atrial Fibrillation because this increases risk of bleeding substantially.
- Why are there two scores for CHADSVAC?
EMIS score is from when it was last coded in the GP record and the CHADSVASC - APL score is from the date the data was run.
- What about the other data on the data sheet e.g. SMI, learning disabilities, other risks?
It gives the opportunities for practices to discuss with the patient if there might be issues with adherence or other relevant issues