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JUNE 2018 HEALTHAWARENESS.CO.UK
HOW YOUR PHARMACIST can spot hidden signs of a stroke P3
A ’SIMPLE FAINT’ Why there is no such thing P4
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AF & Stroke
Atrial fibrillation increases your risk of stroke by five times With better diagnosis and treatment of atrial fibrillation (AF), we could stop around 7,000 strokes and save over 2,000 lives every year in England alone.
A
stroke is a brain attack – it happens when the blood supply to part of the brain is cut off. The impact of a stroke can transform a person’s life – many people will be left with a long-term disability, which could affect their ability to walk, talk or return to work. Stroke strikes in an instant and can affect anyone at any time with devastating consequences. In 2016, 38,000 people in the UK died of a stroke – that’s more than the entire population of Exmouth – and stroke killed twice as many women than breast cancer. Not only does stroke kill, but it is the leading cause of disability. Of everyone who has a stroke, almost two thirds leave hospital with a disability. But all of this can be avoided. Nine out of ten strokes are preventable. One way to prevent strokes is through better diagnosis and treatment of atrial fibrillation (AF).
What is atrial fibrillation? AF is an irregular heartbeat. If you have AF, your heart may beat abnormally fast. More than one million people in the UK have AF and their risk of a stroke is five times greater than someone without AF. AF increases your risk of stroke because your heart is not pumping
• breathlessness • chest pain • fatigue However, some people do not have any symptoms and AF is often only diagnosed during a general medical check up.
What causes AF Juliet Bouverie Chief Executive, Stroke Association
“In 2016, stroke killed twice as many women as breast cancer.” blood as well as it should, which may mean that blood collects inside the heart and a blood clot may form. There is a risk that this clot could then travel through your body to your brain. If the clot blocks one of the arteries leading to your brain, it could cause a stroke
Signs and symptoms of AF Some common symptoms of AF are: • palpitations (being aware of your heart beating fast)
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Some medical conditions increase your chances of developing AF. These include heart problems, such as coronary heart disease, or disease of your heart’s valves. It can also be caused by other conditions, including an overactive thyroid gland, high blood pressure, lung infections like pneumonia, or a blood clot in the lung (pulmonary embolism). Drinking too much alcohol or caffeine, taking illegal drugs, such as cocaine or amphetamines and smoking can all trigger an episode of AF.
What to do if you think you have AF AF is a manageable condition. If you think you may have AF, it is important to talk to your GP. Your GP will check your pulse and they may refer you for further tests. If AF is diagnosed it can be treated, which will reduce your risk of stroke. The main treatment to reduce
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your stroke risk is blood thinning medication (anticoagulants). It’s important that you discuss all options with your GP, to make sure you receive the best treatment possible to reduce your risk of stroke. Aspirin monotherapy (being treated just with aspirin) is no longer recommended to reduce your risk of stroke.
What more needs to be done? We know that, in the UK, it is estimated that half a million people could have AF and not know about it. And that’s not all – we know that fewer than half of UK patients with known AF are on anticoagulant medication when they go to the hospital with a stroke. With better diagnosis and treatment of AF, we could stop around 7,000 strokes and save over 2,000 lives every year in England alone. That’s why we’re urging all clinical commissioning groups to use the NHS Right Care prevention pathway to help identify and treat people with AF. Juliet Bouverie Read more on healthawareness.co.uk PLEASE RECYCLE AFTER READING
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Improving patient safety in atrial fibrillation Dr Matt Kearny National Clinical Director for Cardiovascular Disease Prevention, NHS England
Optimal anticoagulation is key to averting strokes in patients with atrial fibrillation, but in too many cases patients are missing out on the right treatment. Dr Matt Kearney explores the reasons why.
While diagnosis of atrial fibrillation has recently improved at primary care level, some estimated 18-20% of patients are still not taking the anti-coagulants they need to manage the condition. Reasons for this are varied and complex. Many older patients who still associate warfarin with rat poison can be reluctant to take the drug, while the frequent blood tests that warfarin requires can act to deter many others. Newer anti-coagulants (the NOACs and DOACs) are increasingly being used to treat atrial fibrillation and, as they have the advantage of not requiring blood tests for routine anticoagulation monitoring, patients find them easier to use. When treating frailer patients with atrial fibrillation, GPs concerned about risk factors will sometimes pursue a more cautious approach, either failing to prescribe anticoagulants altogether or to treat instead with aspirin. While aspirin is no longer recommended as a blood thinner for atrial fibrillation patients, emerging evidence also suggests that the benefits of anticoagulation treatment almost always outweigh the potential dangers of a bleed.
Shared decision making For these reasons and more, sharing decision making about anticoagulation treatment is key to ensuring informed choice with patients, and a number of tools have been developed of late to facilitate exactly this. The initiative is supported by the presence of more pharmacists in GP practices who have been placed in charge of managing patients’ anticoagulation treatment, as well as taking pulse checks. As time and effort needs to be put into getting patients on the right dosage of anticoagulants if the treatment is to prove maximally effective, it’s a task that pharmacists are well placed to do. Primary care practitioners who are under-confident in diagnosing atrial fibrillation—often if a patient’s condition is intermittent, for example—may benefit from upskilling. While more efficient treatment pathways are needed in areas where unwarranted variation is an issue. Between presenting with the condition and securing the right medication is a time of very high risk for patients. By putting new measures in place though, better outcomes can be realised. EDX/18/0302 June 2018
Victoria Briggs
The risks and benefits of anticoagulation treatment Atrial fibrillation patients should be made aware of the risks and benefits of different types of anticoagulation treatments — and then have a say about which they would rather receive.
Recent figures show that an estimated 1.4 million people are at risk of strokes in the UK due to non-valvular atrial fibrillation (AF). Yet, ensuring they receive optimal treatment for AF isn’t always straightforward, says Professor Anthony Rudd, National Clinical Director for Stroke, NHS England. First, because anticoagulation treatment carries a bleeding risk, medical professionals have to decide which AF patients to give it to. Those with a CHADS-VASc score of two or over usually receive anticoagulation drugs as a matter of course. “However, the benefits of anticoagulation treatment for patients with a CHADS-VASc score of below two are outweighed by its risks,” says Rudd. “It’s therefore not recommended for them. But as their score increases — and it inevitably will as they get older because of the associated risk of stroke — they should receive it.”
Management of warfarin Rudd notes that current medical guidelines recommend treatment with either established anticoagulants or newer Direct Oral Anticoagulants (DOACS). Nothing else will do — and that includes aspirin. “Many AF patients still take aspirin, believing they are achieving something useful by doing so,” says Rudd. “But they aren’t, as their specialist should be able to tell them.” Optimising the dose for each AF patient can be difficult, particularly when prescribing warfarin, warns Rudd. “Warfarin is a difficult drug to manage,” he says. “The dose needed to produce effective anticoagulation will vary from patient to patient; plus, warfarin’s efficacy may be disrupted by factors such as other medications, excess alcohol, or certain foods. It needs regular
Professor Anthony Rudd National Clinical Director for Stroke, NHS England.
“1.4 million people are at risk of strokes in the UK.” monitoring to check that the patient is not being under-treated — or over-treated, which is more likely to cause bleeds.”
Benefits of newer AF drugs This is why many healthcare professionals now recommend the newer DOACs to treat the condition. “We know that the prescribed dose of these drugs will, by and large, have a consistent effect on everyone who takes it, which means AF patients don’t need to be regularly monitored with anticoagulation blood tests,” says Rudd. Also, because the efficacy of warfarin can drop off due to disrupting factors, DOACs may overcome the problem of patients spending time outside of the Therapeutic Range — and therefore at risk of stroke. DOACs do, however, have downsides. “Only one of them has a reversing agent, whereas there is an effective and quick way to reduce warfarin treatment if a patient starts to bleed,” says Rudd. “The new drugs are
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The hidden heart condition that your pharmacist can detect Jane Devenish Pharmacist, Well Pharmacy
Spotting the hidden signs of potential strokes and heart disease is all in a day’s work for your local pharmacist. Are you getting the most out of yours?
For many people with atrial fibrillation, the first time they discover they have the heart condition is when they suffer a stroke. While some with atrial fibrillation (AF) might typically experience symptoms such as dizziness, palpitations or a shortness of breath, others will have no symptoms at all. There are an estimated 67,000 undetected cases of AF in London alone. When AF is diagnosed and managed correctly with anticoagulants, the likelihood of an individual suffering a stroke is significantly reduced.
Pharmacists play important healthcare role
also a lot more expensive. But doctors and patients are now voting with their feet and the latest figures show that over half of all prescribed anticoagulants are DOACs.” There are financial consequences to this, agrees Rudd; but, he argues, if these drugs are more effective at preventing strokes then their cost could be justified. “Over a five-year period, the health care cost for someone with an AF-induced stroke could be as much as £100,000,” he says.
Sharing decision-making It’s important for healthcare professionals to fully inform patients about these possible treatment choices, and then share decisionmaking with them. “Patients must
understand the risk and benefits of both sorts of treatments — or of not receiving any treatment,” says Rudd. “Unless there are special circumstances, I’m fairly forceful that anticoagulation is the best course, because the consequences of not being treated can be so great.” More has to be done to understand unwarranted variation in AF-related strokes, admits Rudd. “There are some centres that have done excellent work to improve detection rates and treatment rates: Bradford, for example, and Lambeth and Southwark in London. It’s interesting that patients from the least deprived areas of Britain are more likely to have a prior history of AF — although it’s not clear why.” Tony Greenway
Pharmacists can play an important role in identifying atrial fibrillation and helping those patients with the condition to manage it effectively, ensuring they get the proper support and treatment they need. No appointment is necessary to see a pharmacist and, as most pharmacies have a private consulting room, patients can be sure of a confidential chat. As highly trained healthcare professionals, pharmacists are ideally placed to determine if someone has an irregular heartbeat—the telltale sign of atrial fibrillation—via a simple pulse check and blood pressure screening that will either be offered free or low cost. Atrial fibrillation is a long-term condition and a patient’s treatment needs can change over time. A pharmacist can help patients to understand their condition, make sure their medication is working as effectively as it should, and help them to make decisions about their care.
Spotting hidden dangers Pharmacists are also very experienced in supporting AF patients with other co-existing health issues, and protecting them from potentially harmful interactions with other types of drugs they are taking. Antihistamines taken for hay fever and decongestants for colds, for example, can cause complications in those with heart rhythm disturbances. A pharmacist can advise on which over the counter medications are best avoided, and where better alternatives exist instead. In the case of atrial fibrillation, or any other condition, a pharmacist will always discuss the level of urgency with a patient, advising them when to see a GP or instigating further tests. While pharmacists are not a replacement for GPs, they do provide important healthcare advice, and can be relied upon as a trusted source of medical guidance, health information, and medicine support. Victoria Briggs
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Why a ‘simple’ faint can warn of a fatal, irregular heart rhythm condition Healthcare professionals and the public often fail to take syncope (fainting) seriously, but it can be a sign of a potentially fatal heart rhythm disorder – arrhythmia.
“
There’s no such thing as a ‘simple’ faint. We must take fainting to heart,” says Trudie Lobban MBE, Founder of heart rhythm charity, Arrhythmia Alliance and sister charity STARS (Syncope Trust And Reflex anoxic Seizures). “One in two people will faint at some point in their life. Syncope may be the only sign of a serious, heart rhythm disorder known as an arrhythmia.” Arrhythmias are frequently left undiagnosed or misdiagnosed and can cause people to faint. An estimated 39% of children and 30% of adults diagnosed with epilepsy actually have an underlying, potentially fatal, arrhythmia,” says Trudie.
Trudie Lobban Founder and Trustee, Arrythmia Alliance
Early detection leading to diagnosis is essential to avoid devastating consequences such as stroke and sudden cardiac arrest. The cheapest and easiest way to detect an arrhythmia is with a simple pulse check. “By checking
“39% of children and 30% of adults diagnosed with epilepsy actually have an underlying, potentially fatal, arrhythmia.” an individual’s pulse, a fast, slow or unsteady heart rhythm may be noticed,” says Trudie. Treatment ranges from lifestyle changes, such as exercise and rehydration, to the implant of a pacemaker which can be fitted in under a day,
often with local anaesthetic. In a bid to cut deaths, STARS has launched new information resources on syncope alongside a revamped, award-winning blackouts checklist, which individuals can complete to support diagnosis. Trudie urges people who experience syncope to take it seriously and request an ECG to test for an arrhythmia. To HCPs, she says: Take fainting to heart – there is no such thing as a simple faint...” Linda Whitney
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