Dr Geert-Jan Geersing – Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands

What do the 2016 ESC guidelines on atrial fibrillation say and what are the implications for primary care?

 
Based on a case presentation and the acronym DUBLIN-AF care, dr. Geersing presented how atrial fibrillation (AF) can be optimally managed in primary care, per the latest guidelines. D is for ‘diagnosis and detect’, which is important, but beyond the scope of the current talk.
 
U stands for ‘use anticoagulants’. It is important to realised that the ESC guideline, as well as the EPCCS consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care, express a preference for non-VKA oral anticoagulants (NOACs) over vitamin K antagonists. A risk score should be used to assess whether a patient should receive anticoagulation. The CHA₂DS₂-VASc score is recommended by both guidance documents. While this risk score is not perfect to predict stroke risk, especially from a score of 2 and higher, it is generally wise to start anticoagulation. For most elderly patients there is a clear benefit of treatment with anticoagulants for stroke prevention. In case of a CHA₂DS₂-VASc score or 1, things are less clear. For instance, while being female counts as one, female gender alone is not a reason to start anticoagulation. In patients with a score of 1, it is important to engage the patient more and to reach a decision via shared decision making. Also factors not incorporated in the CHA₂DS₂-VASc score, such as renal factors, should be considered in this process.
 
B refers to ‘bleeding complications’. Studies comparing treatment with NOACs or VKA, show that a different bleeding pattern is seen. NOACs result less often in intracranial haemorrhages (-50%), while 15% more gastrointestinal bleedings are seen. Depending on the dose and the specific NOAC, all-cause bleeding is reduced by 0-30%. When a bleeding is resolved, it is important to look at modifiable bleeding risk factors. These were previously identified using the HAS-BLED score, but in the latest AF guidelines, this score has disappeared from the guidelines.
As a consequence of fear of bleeding, patients sometimes receive a lower dose of anticoagulation. Reduced doses are less effective and therefore generally not recommended. The risk of not preventing stroke outweighs the risk of bleeding. The patient weighs stroke risk as more important, but doctors sometimes do not.
 
With L, he meant to emphasise the need to ‘look at other co-morbidities’. AF can be considered a systemic disorder, with many conditions intersecting. Primary care can play an important role as the boundary specialist that oversees the total picture. Appreciating co-morbidities is particularly important in the elderly. A sub-study of the ARISTOTLE trial has shown that the efficacy profile of treatment with apixaban as compared with VKA is maintained despite polypharmacy, even in patients taking 9 or more medications. The impact on major bleedings declines, with less benefit of the NOAC as compared to VKA in those taking 9 drugs or more.
 
And IN, finally, refers to ‘integrated care’. While cardiology should be in the lead concerning acute rate and rhythm control and assessment of symptoms and interventions to improve symptoms, primary care should be in the lead to manage precipitating factors, to assess stroke risk, to assess heart rate and to give therapy to address these factors and to stimulate lifestyle changes and treat co-morbid conditions. Care for AF patients will therefore benefit from a good interaction between cardiologists and primary care as boundary specialists.