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Atrial fibrillation overview

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Atrial fibrillation

About

What is covered

This pathway covers the diagnosis and management of atrial fibrillation. It applies to adults (18 years or older) with new-onset or acute atrial fibrillation or chronic atrial fibrillation, including paroxysmal (recurrent), persistent and permanent atrial fibrillation. It does not apply to people with congenital heart disease precipitating atrial fibrillation.
Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing. If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age.
The aim of treatment is to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke and antiarrhythmics to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non-pharmacological management includes electrical cardioversion, which may be used to 'shock' the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the abnormal electrical impulses that cause atrial fibrillation.

Updates

Updates to this pathway

31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to left atrial ablation and a pace and ablate strategy.
22 September 2015 Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (NICE technology appraisal guidance 355) and edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added to anticoagulation treatment.
8 July 2015 Atrial fibrillation: treatment and management (NICE quality standard 93) added.
23 September 2014 Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor) (NICE diagnostics guidance 14) added to assessing anticoagulation control with vitamin K antagonists.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Atrial fibrillation: the management of atrial fibrillation

What is covered

This pathway covers the diagnosis and management of atrial fibrillation. It applies to adults (18 years or older) with new-onset or acute atrial fibrillation or chronic atrial fibrillation, including paroxysmal (recurrent), persistent and permanent atrial fibrillation. It does not apply to people with congenital heart disease precipitating atrial fibrillation.
Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing. If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age.
The aim of treatment is to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke and antiarrhythmics to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non-pharmacological management includes electrical cardioversion, which may be used to 'shock' the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the abnormal electrical impulses that cause atrial fibrillation.

Updates

Updates to this pathway

31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added to left atrial ablation and a pace and ablate strategy.
22 September 2015 Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (NICE technology appraisal guidance 355) and edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added to anticoagulation treatment.
8 July 2015 Atrial fibrillation: treatment and management (NICE quality standard 93) added.
23 September 2014 Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor) (NICE diagnostics guidance 14) added to assessing anticoagulation control with vitamin K antagonists.

Sources

NICE guidance and other sources used to create this pathway.
Atrial fibrillation (2014) NICE guideline CG180
Dronedarone for the treatment of non-permanent atrial fibrillation (2010) NICE technology appraisal guidance 197
Thoracoscopic epicardial radiofrequency ablation for atrial fibrillation (2009) NICE interventional procedure guidance 286
Percutaneous radiofrequency ablation for atrial fibrillation (2006) NICE interventional procedure guidance 168
Atrial fibrillation: treatment and management (2015) NICE quality standard 93

Quality standards

Atrial fibrillation

These quality statements are taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice for atrial fibrillation: treatment and management and should be read in full.

Quality statements

Anticoagulation to reduce stroke risk

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.

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]

Use of aspirin

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.

Quality statement

Adults with atrial fibrillation are not prescribed aspirin as monotherapy for stroke prevention.

Rationale

The risks of taking aspirin outweigh any benefits of taking it as monotherapy for stroke prevention in adults with atrial fibrillation. Healthcare professionals should be aware that adults with atrial fibrillation may need to take aspirin for other indications.

Quality measures

Structure
Evidence of local monitoring arrangements to ensure that adults with atrial fibrillation are not prescribed aspirin as monotherapy for stroke prevention.
Data source: Local data collection.
Process
Proportion of adults with atrial fibrillation who are prescribed aspirin as monotherapy for stroke prevention.
Numerator – the number in the denominator who are prescribed aspirin as monotherapy for stroke prevention.
Denominator – the number of adults with atrial fibrillation.
Data source: Local data collection. Data can be collected using the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP), question 2.1.6.
Outcome
Rates of prescribing aspirin.
Data source: Local data collection.

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

Service providers (primary and secondary care services) monitor prescribing of pharmacological treatment(s) for adults with atrial fibrillation and have protocols in place to ensure that aspirin is not prescribed as monotherapy for stroke prevention.
Healthcare professionals do not prescribe aspirin as monotherapy for stroke prevention for adults with atrial fibrillation.
Commissioners (NHS England area teams and clinical commissioning groups) specify that primary and secondary care services ensure that aspirin is not prescribed as monotherapy for stroke prevention for adults with atrial fibrillation.

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

Adults with atrial fibrillation are not prescribed aspirin on its own for preventing stroke.

Source guidance

  • Atrial fibrillation (2014) NICE guideline CG180, recommendation 1.5.15 (key priority for implementation)

Definitions of terms used in this quality statement

Aspirin as monotherapy for stroke prevention
Adults with atrial fibrillation might be taking aspirin for a variety of other conditions; if so, this may result in the person taking aspirin (for the other conditions) as well as anticoagulants. If a person chooses not to take anticoagulants, this decision and the reason(s) for it should be documented.
[Atrial fibrillation (NICE guideline CG180), full guideline]

Discussing options for anticoagulation

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.

Quality statement

Adults with atrial fibrillation who are prescribed anticoagulation discuss the options with their healthcare professional at least once a year.

Rationale

Adults with non-valvular atrial fibrillation should have the opportunity to discuss the choice of suitable anticoagulants with their healthcare professional, in order to improve adherence to treatment. Available options should include vitamin K antagonists (such as warfarin) and non-vitamin K antagonist oral anticoagulants (NOACS; that is, apixaban, dabigatran etexilate and rivaroxaban). In adults with valvular atrial fibrillation, only vitamin K antagonists can be used, and this should be explained to the person. Adherence to anticoagulation can help to prevent stroke by reducing the likelihood of a blood clot forming.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with atrial fibrillation who are prescribed anticoagulation can discuss the options with their healthcare professional at least once a year.
Process
Proportion of adults with atrial fibrillation who are prescribed anticoagulation who discuss the options with their healthcare professional at least once a year.
Numerator – the number in the denominator who discuss the options with their healthcare professional at least once a year.
Denominator – the number of adults with atrial fibrillation who are prescribed anticoagulation.
Data source: Local data collection.
Outcome
a) Patient experience.
Data source: Local data collection.
b) Rates of adherence to anticoagulation therapy for adults with atrial fibrillation.
Data source: Local data collection.

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

Service providers (primary and secondary care services) have protocols in place to ensure that adults with atrial fibrillation who are prescribed anticoagulation can discuss the options with their healthcare professional at least once a year.
Healthcare professionals discuss the options at least once a year with adults with atrial fibrillation who are prescribed anticoagulation. There should not be mandatory use of vitamin K antagonists before offering non-vitamin K antagonist oral anticoagulants for people with non-valvular atrial fibrillation.
Commissioners (NHS England area teams and clinical commissioning groups) specify that primary and secondary care service providers have protocols in place to ensure that adults with atrial fibrillation who are prescribed anticoagulation can discuss the options with their healthcare professional at least once a year.

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

Adults with atrial fibrillation who are prescribed an anticoagulant have the chance to talk with their doctor at least once a year about the types of anticoagulant they could have and the advantages and disadvantages of each.

Source guidance

  • Atrial fibrillation (2014) NICE guideline CG180, recommendations 1.5.4, 1.5.6, 1.5.8 and 1.5.10

Definitions of terms used in this quality statement

Anticoagulants
Anticoagulants for people with atrial fibrillation include vitamin K antagonists (such as warfarin) and non-vitamin K antagonist oral anticoagulants (NOACS; that is, apixaban, dabigatran etexilate and rivaroxaban).
[Adapted from Atrial fibrillation (NICE guideline CG180)]
Discuss
Any discussion with an adult with atrial fibrillation should involve both oral and written information. A patient decision aid, such as that accompanying NICE’s guideline on atrial fibrillation, can be used to inform the discussion. A discussion should take place at least once a year to review the need and quality of anticoagulation.
[Adapted from Atrial fibrillation (NICE guideline CG180), recommendation 1.5.18, Patient experience in adult NHS services (NICE guideline CG138), recommendation 1.5.12, and expert consensus]

Equality and diversity considerations

Discussions with adults with atrial fibrillation about choice of anticoagulants should take into account any additional needs, such as physical, sensory or learning disabilities, and people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Anticoagulation control

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.

Quality statement

Adults with atrial fibrillation taking a vitamin K antagonist who have poor anticoagulation control have their anticoagulation reassessed.

Rationale

Improving poor anticoagulation control by reassessing the international normalised ratio (INR) at each visit can ensure that a person’s risks of stroke and of having a major bleed are as low as possible.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with atrial fibrillation taking a vitamin K antagonist have their anticoagulation reassessed if their anticoagulation control is poor.
Data source: Local data collection.
Process
a) Proportion of adults with atrial fibrillation taking a vitamin K antagonist who have their time in therapeutic range (TTR) recorded at each visit for INR assessment.
Numerator – the number in the denominator who have their TTR recorded at each visit for INR assessment.
Denominator – the number of adults with atrial fibrillation taking a vitamin K antagonist.
Data source: Local data collection.
b) Proportion of adults with poor anticoagulation control who have it reassessed.
Numerator – the number in the denominator who have their anticoagulation reassessed.
Denominator – the number of adults with poor anticoagulation control.
Data source: Local data collection.
Outcome
a) Rates of thromboembolic complications.
Data source: Local data collection.
b) Patient experience.
Data source: Local data collection.

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

Service providers (secondary care services) have systems in place with written clinical protocols for reassessing anticoagulation in adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.
Healthcare professionals reassess anticoagulation and record the results for adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.
Commissioners (clinical commissioning groups) commission secondary care services that have written clinical protocols for reassessing anticoagulation in adults with atrial fibrillation who are taking a vitamin K antagonist and have poor anticoagulation control.

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

Adults with atrial fibrillation who are taking a type of anticoagulant called a vitamin K antagonist (such as warfarin) have their anticoagulation treatment reassessed if regular tests show that it isn’t working well.

Source guidance

  • Atrial fibrillation (2014) NICE guideline CG180, recommendations 1.5.11 (key priority for implementation), 1.5.12, 1.5.13 and 1.5.14 (key priority for implementation)

Definitions of terms used in this quality statement

Poor anticoagulation control
Poor anticoagulation control can be shown by any of the following:
  • 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months
  • 2 INR values less than 1.5 within the past 6 months
  • TTR less than 65%.
The NICE guideline on atrial fibrillation recommends that TTR is measured at each visit and at least annually, and that healthcare professionals should:
  • use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing
  • exclude measurements taken during the first 6 weeks of treatment
  • calculate TTR over a maintenance period of at least 6 months.
[Atrial fibrillation (NICE guideline CG180), recommendations 1.5.11, 1.5.12 and 1.5.18]
Reassessing anticoagulation
The NICE guideline on atrial fibrillation recommends that the following factors should be taken into account and addressed if they are contributing to poor anticoagulation control:
  • cognitive function
  • adherence to prescribed therapy
  • illness
  • interacting drug therapy
  • lifestyle factors including diet and alcohol consumption.
If poor anticoagulation control cannot be improved as a result of this reassessment, the risks and benefits of alternative stroke prevention strategies should be evaluated and discussed with the person.
[Adapted from Atrial fibrillation (NICE guideline CG180), recommendations 1.5.13 and 1.5.14]

Referral for specialised management

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.

Quality statement

Adults with atrial fibrillation whose treatment fails to control their symptoms are referred for specialised management within 4 weeks.

Rationale

Prompt referral of adults with atrial fibrillation to specialised management if treatment fails can help to alleviate symptoms and reduce the likelihood of poor outcomes such as stroke and heart failure.

Quality measures

Structure
Evidence of local arrangements and referral pathways to ensure that adults with atrial fibrillation whose treatment fails to control their symptoms are referred for specialised management within 4 weeks.
Data source: Local data collection.
Process
Proportion of adults with atrial fibrillation whose treatment fails to control their symptoms who are referred for specialised management within 4 weeks.
Numerator – the number in the denominator who are referred for specialised management within 4 weeks.
Denominator – the number of adults with atrial fibrillation whose treatment fails to control their symptoms.
Data source: Local data collection.
Outcome
a) Adults with atrial fibrillation symptom control.
Data source: Local data collection.
b) Rates of stroke and heart failure for adults with atrial fibrillation.
Data source: Local data collection.

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

Service providers (primary and secondary care services) have procedures in place to ensure that adults with atrial fibrillation whose treatment fails to control their symptoms are referred for specialised management within 4 weeks.
Healthcare professionals refer adults with atrial fibrillation whose treatment fails to control their symptoms, to specialised management within 4 weeks.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that primary and secondary care providers have procedures in place so that adults with atrial fibrillation whose treatment fails to control their symptoms are referred for specialised management within 4 weeks.

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

Adults with atrial fibrillation who still have symptoms after treatment are referred within 4 weeks for specialised care that aims to ease their symptoms and reduce their risk of having a stroke or heart failure.

Source guidance

  • Atrial fibrillation (2014) NICE guideline CG180, recommendation 1.3.1 (key priority for implementation)

Definitions of terms used in this quality statement

Fails to control symptoms
Adults whose treatment fails to control the symptoms of atrial fibrillation at any stage.
[Adapted from Atrial fibrillation (NICE guideline CG180), recommendation 1.3.1]
Referred within 4 weeks
Referral should be no longer than 4 weeks after the final failed treatment or no longer than 4 weeks after recurrence of atrial fibrillation after cardioversion.
[Adapted from Atrial fibrillation (NICE guideline CG180), recommendation 1.3.1]
Specialised management
Specialised management can be provided by an ‘atrial fibrillation specialist’ such as a cardiologist or nurse with an interest in arrhythmia. Specialised management should be provided through a package of care that covers key elements of service provision, tailored to the person with atrial fibrillation. Formally documenting key elements of the service can help to ensure that it has been delivered.
[Atrial fibrillation (NICE guideline CG180), full guideline]

Self-monitoring of anticoagulation: developmental

This quality statement is taken from the atrial fibrillation: treatment and management quality standard. The quality standard defines clinical best practice in atrial fibrillation: treatment and management and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Developmental quality statement

Adults with atrial fibrillation on long-term vitamin K antagonist therapy are supported to self-manage with a coagulometer.

Rationale

Enabling adults with atrial fibrillation to self-manage their coagulation using a coagulometer can help to optimise their anticoagulation treatment. As well as reducing the frequency of hospital or clinic visits, it can improve health outcomes such as risk of stroke and bleeding.

Quality measures

Structure
Evidence of local arrangements for adults with atrial fibrillation on long-term vitamin K antagonist therapy to be supported to self-manage with a coagulometer.
Data source: Local data collection.
Process
Proportion of adults with atrial fibrillation on long-term vitamin K antagonist therapy who are supported to self-manage with a coagulometer.
Numerator – the number in the denominator who are supported to self-manage with a coagulometer.
Denominator – the number of adults with atrial fibrillation on long-term vitamin K antagonist therapy.
Data source: Local data collection.
Outcome
a) Patient experience.
Data source: Local data collection.
b) Rates of adults on long-term vitamin K antagonist therapy who self-manage.
Data source: Local data collection.

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

Service providers (secondary care services) make coagulometers for self-monitoring available to adults with atrial fibrillation who are on long-term vitamin K antagonist therapy, and ensure that support is available for their use.
Healthcare professionals offer coagulometers to adults with atrial fibrillation who are on long-term vitamin K antagonist therapy so that they can self-monitor their coagulation status, provided that they are willing and able to do so. Healthcare professionals also provide support for people using the coagulometers.
Commissioners (clinical commissioning groups) ensure that secondary care providers have coagulometers for self-monitoring available and offer them to adults with atrial fibrillation who are on long-term vitamin K antagonist therapy, and provide support for their use.

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

Adults with atrial fibrillation who are taking a vitamin K antagonist over a long time are (if appropriate) offered a monitor they can use to help check how well the treatment is working, if they want to use the monitor and can do so. They are also given support by healthcare professionals to use the monitor.

Source guidance

Definitions of terms used in this quality statement

Coagulometer
Coagulometers monitor blood clotting in adults taking anticoagulants.
The CoaguChek XS system and INRatio2 PT/INR monitor are recommended for self-monitoring coagulation status in adults on long-term vitamin K antagonist therapy who have atrial fibrillation if:
  • the person prefers this form of testing and
  • the person or their carer is both physically and cognitively able to self‑monitor effectively.
Support
Patients and carers should be trained in the effective use of the CoaguChek XS system or the INRatio2 PT/INR monitor and clinicians involved in their care should regularly review their ability to self-monitor. Equipment for self‑monitoring should be regularly checked using reliable quality-control procedures, and by testing patients' equipment against a healthcare professional's coagulometer which is checked in line with an external quality assurance scheme. Ensure accurate patient records are kept and shared appropriately.

Equality and diversity considerations

For adults with atrial fibrillation who may have difficulty with or who are unable to self-monitor, such as people with disabilities, the possibility of their carers helping with self-monitoring should be considered. Coagulometers currently come at a cost to the adult with atrial fibrillation, so reasonable adjustments should be made for the socioeconomic status of the adult.

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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Bispectral Index
electroencephalography
electrocardiogram
international normalised ratio
atrial fibrillation that terminates spontaneously within 7 days, usually within 48 hours
the person managing paroxysmal atrial fibrillation themselves by taking antiarrhythmic drugs only when an episode of atrial fibrillation starts
no longer than 4 weeks after the final failed treatment or no longer than 4 weeks after recurrence of atrial fibrillation following cardioversion
time in therapeutic range

Paths in this pathway

Pathway created: June 2014 Last updated: April 2016

© NICE 2016

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