Quality statement 1: Anticoagulation to reduce stroke risk

Quality statement

Adults with non‑valvular atrial fibrillation and a CHA2DS2-VASC stroke risk score of 2 or above are offered anticoagulation.

Rationale

Adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above are at a much higher risk of having a stroke than the general population. Anticoagulation therapy can help to prevent strokes by reducing the likelihood of a blood clot forming. A person's bleeding risk should be taken into account in reaching a decision about anticoagulation, although for most people the benefit of anticoagulation outweighs the bleeding risk.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above are offered anticoagulation.

Data source: Local data collection.

Process

Proportion of adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above who receive anticoagulation.

Numerator – the number in the denominator who receive anticoagulation.

Denominator – the number of adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above.

Data source: Local data collection. Data can be collected using Quality and Outcomes Framework indicator AF007.

Outcome

Stroke rates in adults with a primary diagnosis of non‑valvular atrial fibrillation.

Data source: Local data collection. Data can be collected using the Royal College of Physicians' Sentinel Stroke National Audit Programme (SSNAP), question 2.1.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary, secondary and tertiary care services) have written clinical protocols in place to ensure that anticoagulation is offered to adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above.

Healthcare professionals offer anticoagulation to adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above.

Commissioners (NHS England area teams and clinical commissioning groups) commission primary, secondary and tertiary care services with written clinical protocols to ensure that adults with non‑valvular atrial fibrillation and a CHA2DS2‑VASC stroke risk score of 2 or above are offered anticoagulation.

What the quality statement means for patients, service users and carers

Adults with a type of atrial fibrillation called 'non‑valvular' who are identified by their doctor as being at higher risk of having a stroke are offered treatment with a medicine called an anticoagulant, to lower their risk of having a blood clot that could cause a stroke.

Source guidance

Atrial fibrillation (2014) NICE guideline CG180, recommendation 1.5.3 (key priority for implementation)

Definitions of terms used in this quality statement

CHA2DS2‑VASc stroke risk score

The CHA2DS2-VASc stroke risk score estimates the risk of stroke in people with non‑valvular atrial fibrillation on a point scale of 1–9, using the following risk factors:

  • aged 65–74 years (1 point)

  • aged 75 years or older (2 points)

  • female (1 point)

  • congestive heart failure (1 point)

  • hypertension (1 point)

  • diabetes (1 point)

  • stroke, transient ischaemic attack or thromboembolism (2 points)

  • vascular disease – previous myocardial infarction, peripheral arterial disease, aortic plaque (1 point).

The NICE guideline on atrial fibrillation recommends that bleeding risk, estimated using the HAS-BLED score, is taken into account when offering anticoagulation. The HAS‑BLED score estimates the risk of bleeding on a point scale of 1–9. Each of the following risk factors represents 1 point:

  • hypertension (uncontrolled; for example, systolic blood pressure higher than 160 mmHg)

  • renal disease (chronic dialysis, renal transplantation or serum creatinine of 200 micromol/litre or more)

  • liver disease (chronic hepatic disease such as cirrhosis or biochemical evidence of significant hepatic derangement [for example, bilirubin more than 2 times upper limit of normal in association with aspartate/alanine aminotransferase or alkaline phosphatase more than 3 times upper limit of normal])

  • stroke

  • major bleeding event or predisposition to bleeding

  • labile international normalised ratio (INR) for people taking vitamin K antagonists, unstable or high INRs or poor time in therapeutic range (for example, less than 60%)

  • age over 65 years

  • use of drugs such as antiplatelet agents or non‑steroidal anti‑inflammatory drugs

  • alcohol misuse or harmful excess.

[Adapted from Atrial fibrillation (NICE guideline CG180), recommendation 1.5.3]