The future of anticoagulation management in atrial fibrillation in Europe

An assessment of today's challenges with recommendations for the future

by Catherine A. Lichten, Sophie Castle-Clarke, Catriona Manville, Veronika Horvath, Enora Robin, Joachim Krapels, Sarah Parks, Megan Sim, Olga van Zijverden, Joanna Chataway

This Article

RAND Health Quarterly, 2015; 5(2):2

Abstract

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting approximately 1–2 per cent of the population worldwide. Those who suffer from AF have a five times higher risk of stroke. AF prevalence increases with age and it affects roughly 18 per cent of the population over 85. Consequently, as populations age, AF is becoming an increasingly significant public health issue. Over recent years there have been developments in treatment and management options, both for treating the arrhythmia directly, and assessing and reducing the risk of AF-related stroke, but there is a need to ensure that available knowledge is applied optimally to benefit patients so that opportunities to prevent AF-related stroke are not missed. The aims of this project were to assess the current landscape and explore the direction of future developments in AF management in Europe, with a focus on the use of anticoagulants in the prevention of AF-related stroke. Through rapid evidence assessment, key informant interviews, PESTLE analysis and the development and exploration of future scenarios, we have developed sets of shorter- and longer-term recommendations for improving AF-related patient outcomes. The short-term recommendations are: i) improve AF awareness among the public and policymakers; ii) support education about AF management for healthcare professionals and patients; and iii) maintain engagement in AF-related research across the health services.

For more information, see RAND RR-1053-UKRF at https://www.rand.org/pubs/research_reports/RR1053.html

Full Text

As populations age, the prevalence of atrial fibrillation (AF), the most common heart arrhythmia, is rising. Bringing a five-fold increase in stroke risk and affecting nearly one in five people over 85, AF constitutes a rapidly growing public health burden for Europe. AF prevalence is predicted to be at least 3.3 per cent by 2050.

The Future of Anticoagulation Initiative

To address this challenge, research organisation RAND Europe has conducted a qualitative analysis of current issues in AF management in Europe and how things could change in the coming 5–10 years, focusing on the use of oral anticoagulants in six European countries (Belgium, France, Germany, Italy, Spain and the UK).* The study is part of the Future of Anticoagulation Initiative, a set of activities aimed at improving anticoagulation care in AF patients.

The study was guided by a steering committee and involved:

  • Reviewing research literature and clinical guidelines.
  • 60 interviews with doctors, patient representatives and others from the six focus countries.
  • Analysis of political, economic, social, technological, legal and environmental factors that impact AF management.
  • Discussion of possible future scenarios for AF management.

What Is AF?

  • AF is the most common type of irregular heart rhythm, or arrhythmia.
  • In AF, contractions of different parts of the heart, the atria and ventricles, become out of sync. Blood can pool in the atria, and blood clots can form. If the clots move to the brain, they may block blood flow and cause an AF-related stroke.
  • AF can be symptomless, or it can cause:
    • Palpitations
    • Breathlessness
    • Chest pain
    • Light-headedness
    • Fatigue
    • Fainting

The Future of Anticoagulation Initiative: International Steering Committee

Representing professional and patient perspectives, the committee guided research, consideration of future scenarios and shaping of recommendations to improve the outlook for AF.

Members:

  • Prof John Camm (Chair), UK
  • Prof Josep Brugada, Spain
  • Prof Jean-Marc Davy, France
  • Prof Raffaele De Caterina, Italy
  • Prof Hans-Christoph Diener, Germany
  • Prof Dr Andreas Goette, Germany
  • Prof Reinhold Kreutz, Germany
  • Trudie Lobban MBE, UK
  • Dr Jonathan Salter, UK
  • Dr Andrew Walker, UK

AF: A Growing Issue

Across Europe, AF prevalence is 2 per cent. As populations age and risk factors such as diabetes and obesity become more common, prevalence is rising.

By 2050, prevalence is predicted to be more than 3 per cent.

The chance of having AF increases with age. Among people over 85, 18 per cent have AF.

AF and stroke:

  • Number of strokes linked to AF: 1 in 5
  • Increase in stroke risk linked to AF: five-fold
Figure 1: AF Prevalence in the EU (projected), Showing Number of Individuals (top) and Percentage of Total Population (bottom) with AF

Figure 1: AF Prevalence in the EU (projected), Showing Number of Individuals (top) and Percentage of Total Population (bottom) with AF

Source: Uses data from Krijthe et al. (2013) and Eurostat (2014). NB: The number of individuals under 75 years of age with AF is expected to decrease between 2040 and 2060 because the population in that age group is expected to decrease.

Figure 2: Summary of Research Approach

Figure 2: Summary of Research Approach

Key Findings

Detection

  • The irregular heart rhythm in AF can be detected with a manual pulse check and verified with an electrocardiogram (ECG).
  • AF is currently under-diagnosed. A significant proportion of AF patients are diagnosed by chance during health checks carried out for other reasons, or following the occurrence of a stroke.
  • Reasons cited for under-diagnosis include the fact that AF can be asymptomatic and a lack of awareness about AF and its symptoms.
  • To increase the chance of detection, the European Society of Cardiology (ESC) recommends that patients at higher risk of having AF be “opportunistically screened” by receiving a pulse check when they visit their doctor.

Management

  • In AF patients, therapies mainly aim to correct the irregular heart rhythm and/or reduce the risk of AF-related stroke (the latter has been the focus of this study).
  • To reduce the risk of AF-related stroke, drugs that prevent blood clot formation, called oral anticoagulants (OACs), are often used.** Doctors assess whether AF patients should receive oral anticoagulants based on their age, gender and other health and lifestyle factors.
  • There are two classes of OACs now available: vitamin K antagonists (VKAs) such as warfarin, which have been the mainstay of oral anticoagulation therapy for many years, and newer non-VKA oral anticoagulants (NOACs). Uptake of NOACs varies across regions and healthcare settings for reasons including cost issues and concerns about bleed risk.
  • Both the underuse and overuse of OACs relative to clinical guidelines are ongoing concerns. There is evidence that patients at high risk of stroke are often not prescribed OACs as well as evidence of over-use of OACs to patients at low risk of stroke.

Looking Towards the Future

As AF becomes more prevalent, it is becoming increasingly important to address the challenges that prevent optimal management of the condition. We developed a set of recommendations, based on our research assessing the current landscape, to enable the best possible outcomes to be achieved from existing knowledge about AF and technology available for AF management, and help create an environment that would support further development in AF knowledge as well as options for treatment and management, and their application. Issues that arose are broadly similar across the six countries of focus, and so the recommendations are relevant to all.

The first set of recommendations are more immediate and relate directly to AF-specific developments, while the others relate to the implications of broader healthcare trends on AF and may require consideration and action over a longer time-frame.

Immediate, AF-Specific Recommendations

1: Improve AF Awareness Among the Public and Policymakers
  • AF awareness is low at present, among both the general public and policymakers.
  • Awareness needs to focus on the concept that AF increases the risk of preventable, AF-related stroke.
  • Improved awareness could eventually lead to earlier detection and intervention, resulting in prevention of AF-related strokes and lives saved.
2: Support Education About AF Management for HCPs and Patients
  • Improved education of healthcare providers (across the broad range of practitioners who are likely to encounter AF) can lead to better guideline adherence and more informed decisions about AF management.
  • Improved patient education can result in better patient adherence and persistence, leading to better patient outcomes.***
  • In AF, the increase in stroke risk associated with non-compliance with anticoagulation therapy is serious.
3: Maintain Engagement in AF-Related Research Across the Health Services
  • Continued progress in AF management would benefit from a whole-system approach involving primary, secondary and tertiary care as well as policymakers.
  • There is a need for research to monitor impacts of interventions in education and other aspects of AF-related healthcare delivery.
  • The involvement of tertiary care is important for progress in research and technology.

Longer-Term Recommendations

1: A Longer-Term View in Decisions on Spending for AF Awareness, Education, Care and Management Is Important for Improving Health Outcomes
  • Improving management of AF-related stroke requires that decisions made across the health system that affect AF management align with current evidence on the effectiveness of therapies and other management interventions.
  • Disconnected budgets within health systems can create obstacles for ensuring consistency in decisionmaking across the system. For example, up-front costs may be a more significant factor in decisions about therapies than longer-term benefits and associated cost savings.
  • There is a particular need for prevention, early detection and whole-patient approaches.
2: There Is a Need for Continued Improvement in Patient Stratification and Personalisation of Care
  • AF patients may present a diversity of preferences, social situations and comorbidities which can be factored in to ensure they receive appropriate AF management.
  • Improved patient stratification based on biomarkers, genomic information and heart imaging can lead to more individualised care that results in more effective management and treatment of AF.
3: Increased Interaction Among Primary, Community, Secondary and Tertiary Care Would Enable Knowledge Sharing and More Whole-Patient Approaches to Care
  • Many AF patients have comorbidities, and so it is important to support continuity of care for AF patients and not manage AF in isolation.
  • In addition to GPs and specialist HCPs, a range of players can contribute to aspects of AF patient management, including pharmacies, care homes and carers, and specialist nurses.
  • It is important to promote interaction and knowledge exchange across actors involved in patient care.
4: Monitor Developments in Devices and Data to Maximise Benefits for AF Management
  • Devices are being developed that can be used in AF detection and therapy.
  • Software and data sharing can facilitate collaboration among HCPs and support decisionmaking, and help to identify high-risk patients who should be screened for AF.
  • Large patient datasets will be useful for research, especially into patient risk stratification and the assessment of the utility and safety of therapeutic interventions, enabling better care.

References

Eurostat. 2014. “Main scenario—Population on 1st January by sex and single year age. Code: proj_13npms.” As of 19 March 2015:
http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=proj_13npms&lang=en

Krijthe, B.P., et al. 2013. “Projections on the number of individuals with atrial fibrillation in the European Union from 2000 to 2060.” European Heart Journal 34(35): 2746–51.

Notes

* The study was carried out following rigorous research methods, but does not constitute a systematic review of evidence. It should also be noted that the findings are based in part on the views of a set of 60 interviewees and the steering committee, and these groups do not constitute a representative sample from across the six countries of focus.

** For patients that cannot receive oral anticoagulants, other options for AF-related stroke prevention may be antiplatelet therapy, and left atrial appendage occlusion, closure or excision (according to the latest guidance from the European Society of Cardiology).

*** In addition to speaking to a doctor, patients may wish to make use of resources provided by a patient association. One example is Atrial Fibrillation Association International: www.afa-international.org

The research described in this article was conducted by RAND Europe.

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.