Cardiovascular disease (CVD), including stroke, is one of the leading causes of death in the UK. It is also the leading cause of avoidable mortality in our most deprived communities and accounts for a fifth of the life expectancy gap between people living in the most affluent areas compared to those living in the most deprived. Atrial fibrillation (AF) is risk factor for CVD and in particular stroke, but the risk can be mitigated to a certain extent with pharmacological therapy.
My interest in stroke has predominantly focused on AF as it has been shown that this condition means that people are five times more likely to have a stroke than somebody who does not have AF.
We also know that by the age of 65, around 4-6% will have AF which increases to around one in 10 of us by the time we reach the age of 80. In addition, around a third of people with AF do not have any symptoms or signs. You can see that there is a big challenge here.
What drew me to the focus on stroke in people with AF is that you are far more likely to be bedridden and have effects to your quality of life compared to people who have a stroke but don’t have AF, yet the risk can be mitigated. Unfortunately, for many people, we only identify them when they have been admitted with having a stroke.
Anticoagulation (blood thinners) provides a real opportunity to change this as it can reduce the risk of stroke by around 66%. To put this into context, that average population risk of stroke is 4-5% but this reduces to below 1.5% with anticoagulation. That is a dramatic reduction.
In my work with my team, we saw that the national rate of anticoagulation was around 65% about 10 years ago and yet 20% of strokes had known AF prior to admission and most were not receiving anticoagulation at the time. A key part of the challenge to increase the national rate of anticoagulation was people’s reluctance and intolerance to warfarin. Since this there has been significant innovation in anticoagulant drugs with the introduction of direct-action oral anticoagulants (DOACs) which are highly effective and don’t require regular blood testing or dietary consideration like warfarin. They also reduce the risk of brain bleeds which is often a huge prescribing concern for people like me when treating patients.
The introduction of DOACS and the national Health Innovation Network AF programme launched in 2018 enabled us to work with our primary care colleagues to review all their patients on the AF register who were suitable for anticoagulation and to get them started on this medication. We also worked on ensuring people with more complex needs were reviewed by multidisciplinary teams and focussed on equity of access for people across North East London.
Originally, North East London were amongst the lowest performers with anticoagulation rates, and now, has one of the top rates of anticoagulation for people with AF – we are hitting rates of 95.5% which I am so proud to have been a part of.
I have also looked at improving detection rates of AF in people aged 65 and over by using digital technologies like Kardia mobile devices and introducing these into community pharmacies to encourage people to get checked. I have worked with my team to set up a pathway to ensure that all patients who have been checked in community pharmacy are reviewed by a specialist within two weeks. We also set up a one stop AF clinic at Whipps Cross Hospital where people can be checked and diagnosed with the condition and see a pharmacist to get their anticoagulants prescribed there and then.
We are now in the process of getting the service commissioned and doing some innovative work with community pharmacies that can incorporate this into their service. Looking ahead we want to do more to detect people with undiagnosed AF and therefore benefit the lives of even more people through reducing their risk of a debilitating stroke.
I am really proud of everything the team working with our collaborating partners as part of an East London Prevention group called ELOPE have achieved so far, and the impact this has had in our region and wider too. Being able to successfully pilot these interventions and processes and receive ICB funding for more specialist pharmacists to work on cardiovascular prevention is very exciting and just goes to show we can break down some of the barriers that exist between primary, secondary and tertiary care.
Sotiris and team are currently working with UCLPartners to roll out lipid point of care testing across pharmacies in North East London. Read more about our work in Cardiovascular health here.