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Atrial fibrillation

About

What is covered

This NICE Pathway covers diagnosing and managing atrial fibrillation in people aged 18 and over 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.

Updates

Updates to this NICE Pathway

2 July 2021 Technology appraisal guidance on apixaban, dabigatran, edoxaban and rivaroxaban in anticoagulation updated to clarify that all the other anticoagulants approved by NICE should be included in risks and benefits discussions before starting treatment.
30 June 2021 Amended the NICE recommendation on using the ORBIT score to assess bleeding risk to reinstate the previous link to an appropriate calculation tool, which was removed in error on 10 June 2021
10 June 2021 Amended the NICE recommendation on using the ORBIT score to assess bleeding risk so that it links to a calculation tool that includes the full list of criteria, including reduced haemoglobin, reduced haematocrit and history of anaemia.
27 April 2021 Updated on publication of the partial update of atrial fibrillation: diagnosis and management (NICE guideline NG196).
17 February 2021 Vernakalant for the rapid conversion of recent onset atrial fibrillation to sinus rhythm (terminated appraisal) (NICE technology appraisal 675) added.
2 September 2020 Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke (NICE diagnostics guidance 41) added.
11 December 2019 Links to the CHA2DS2-VASc tool have been updated.
7 May 2019 Lead-I ECG devices for detecting symptomatic atrial fibrillation using single time point testing in primary care (NICE diagnostics guidance 35) added.
7 February 2018 Atrial fibrillation (NICE quality standard 93) updated.
19 December 2017 Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (NICE diagnostics guidance 14) amended because the INRatio2 PT/INR monitor is no longer available.
26 July 2016 Percutaneous endoscopic catheter laser balloon pulmonary vein isolation for atrial fibrillation (NICE interventional procedures guidance 563) added.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
22 September 2015 Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (NICE technology appraisal guidance 355) added.
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.

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing atrial fibrillation in an interactive flowchart

What is covered

This NICE Pathway covers diagnosing and managing atrial fibrillation in people aged 18 and over 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.

Updates

Updates to this NICE Pathway

2 July 2021 Technology appraisal guidance on apixaban, dabigatran, edoxaban and rivaroxaban in anticoagulation updated to clarify that all the other anticoagulants approved by NICE should be included in risks and benefits discussions before starting treatment.
30 June 2021 Amended the NICE recommendation on using the ORBIT score to assess bleeding risk to reinstate the previous link to an appropriate calculation tool, which was removed in error on 10 June 2021
10 June 2021 Amended the NICE recommendation on using the ORBIT score to assess bleeding risk so that it links to a calculation tool that includes the full list of criteria, including reduced haemoglobin, reduced haematocrit and history of anaemia.
27 April 2021 Updated on publication of the partial update of atrial fibrillation: diagnosis and management (NICE guideline NG196).
17 February 2021 Vernakalant for the rapid conversion of recent onset atrial fibrillation to sinus rhythm (terminated appraisal) (NICE technology appraisal 675) added.
2 September 2020 Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke (NICE diagnostics guidance 41) added.
11 December 2019 Links to the CHA2DS2-VASc tool have been updated.
7 May 2019 Lead-I ECG devices for detecting symptomatic atrial fibrillation using single time point testing in primary care (NICE diagnostics guidance 35) added.
7 February 2018 Atrial fibrillation (NICE quality standard 93) updated.
19 December 2017 Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (NICE diagnostics guidance 14) amended because the INRatio2 PT/INR monitor is no longer available.
26 July 2016 Percutaneous endoscopic catheter laser balloon pulmonary vein isolation for atrial fibrillation (NICE interventional procedures guidance 563) added.
31 March 2016 Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M (NICE diagnostics guidance 6) added.
22 September 2015 Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (NICE technology appraisal guidance 355) added.
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.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Atrial fibrillation: diagnosis and management (2021, updated June 2021) NICE guideline NG196
Dronedarone for the treatment of non-permanent atrial fibrillation (2010 updated 2012) NICE technology appraisal guidance 197
Thoracoscopic epicardial radiofrequency ablation for atrial fibrillation (2009) NICE interventional procedures guidance 286
Percutaneous radiofrequency ablation for atrial fibrillation (2006) NICE interventional procedures guidance 168
Atrial fibrillation (2015 updated 2018) NICE quality standard 93
KODEX-EPD for cardiac imaging during ablation of arrhythmias (2021) NICE medtech innovation briefing 260
microINR for anticoagulation therapy (2021) NICE medtech innovation briefing 257
KardiaMobile for the ambulatory detection of atrial fibrillation (2020) NICE medtech innovation briefing 232

Quality standards

Atrial fibrillation

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

Quality statements

Anticoagulation to reduce stroke risk

This quality statement is taken from the atrial fibrillation quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 the NHS 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 different audiences

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.
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

Definitions of terms used in this quality statement

CHA2DS2-VASC stroke risk score
The stroke risk score estimates the risk of stroke in people with non-valvular atrial fibrillation. [Adapted from NICE’s guideline on atrial fibrillation, recommendations 1.2.1 and 1.6.3]
Bleeding risk score
Bleeding risk, estimated using ORBIT bleeding risk score, should be taken into account when offering anticoagulation. The ORBIT bleeding risk score estimates the risk of bleeding.
Although ORBIT is the best tool for this purpose, other bleeding risk tools may need to be used until it is embedded in clinical pathways and electronic systems. [Adapted from NICE's guideline on atrial fibrillation, recommendation 1.2.2]

Use of aspirin

This quality statement is taken from the atrial fibrillation quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 different audiences

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

Source guidance

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. [NICE’s 2014 full guideline on atrial fibrillation]

Discussing options for anticoagulation

This quality statement is taken from the atrial fibrillation quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 direct-acting oral anticoagulants and vitamin K antagonists. 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 different audiences

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.
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: diagnosis and management. NICE guideline 196 (2021), recommendations 1.4.1, 1.6.1, 1.6.3, 1.6.4 and 1.6.5

Definitions of terms used in this quality statement

Anticoagulants
Anticoagulants for people with atrial fibrillation include direct-acting oral anticoagulants (such as apixaban, dabigatran, edoxaban and rivaroxaban) and vitamin K antagonists. [Adapted from NICE’s guideline on atrial fibrillation, recommendations 1.6.3, 1.6.4 and 1.6.5]
Discuss
Any discussion with an adult with atrial fibrillation should involve both oral and written information. A patient decision aid 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 NICE’s guideline on atrial fibrillation, recommendation 1.6.16, NICE’s guideline on patient experience in adult NHS services, 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 quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 different audiences

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.
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: diagnosis and management. NICE guideline 196 (2021), recommendations 1.6.9, 1.6.10, 1.6.11, 1.6.12 and 1.6.16

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.
[NICE’s guideline on atrial fibrillation, recommendations 1.6.9, 1.6.10 and 1.6.16]
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 NICE’s guideline on atrial fibrillation, recommendations 1.6.11 and 1.6.12]

Referral for specialised management

This quality statement is taken from the atrial fibrillation quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 different audiences

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.
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

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 NICE’s guideline on atrial fibrillation, recommendation 1.5.1]
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 NICE’s guideline on atrial fibrillation, recommendation 1.5.1]
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. [NICE’s 2014 full guideline on atrial fibrillation]

Self-monitoring of anticoagulation: developmental

This quality statement is taken from the atrial fibrillation quality standard. The quality standard defines clinical best practice for atrial fibrillation 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 different audiences

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.
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 is 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 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. [NICE’s diagnostics guidance on atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system), recommendations 1.3 and 1.4]

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.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. 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 guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so 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.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

In people with a diagnosis of atrial fibrillation, do not stop anticoagulation solely because atrial fibrillation is no longer detectable.
Base decisions to stop anticoagulation on a reassessment of stroke and bleeding risk using CHA2DS2-VASc and ORBIT and a discussion of the person's preferences. See assessing stroke and bleeding risk for further information.

Glossary

American College of Cardiology
Bispectral Index
electroencephalography
electrocardiogram
international normalised ratio
left atrial appendage occlusion
non-steroidal anti-inflammatory drugs
(people presenting with atrial fibrillation of definite recent onset or with destabilisation of existing atrial fibrillation; this does not include people with atrial fibrillation that has been discovered incidentally, for example, through pulse palpitation before routine blood pressure measurement)
(episodes of atrial fibrillation that stop within 7 days, usually within 48 hours, without any treatment)
(the person self-manages paroxysmal atrial fibrillation by taking antiarrhythmic drugs only when an episode of atrial fibrillation starts)
selective serotonin reuptake inhibitors
transoesophageal echocardiography
transthoracic echocardiography
time in therapeutic range

Paths in this pathway

Pathway created: June 2014 Last updated: July 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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