GuideforPrimaryCareInitiatinganticoagulationforstrokepreventioninnon-valvularAtrial

Fibrillation

Approved:September2018Reviewdate:September2021

Authors

JagjotKaurChahalHighlySpecialistHaematologyPharmacist,BartsHealthNHSTrustLiseDurandPharmacist,BartsHealthNHSTrustSotirisAntoniouConsultantPharmacistforCardiovascularMedicine,BartsHealthNHSTrustDrKhalidSajaConsultantHaematologist,ColchesterHospitalUniversityNHSFoundationTrustDrMarkEarley ConsultantCardiologist,BartsHealthNHSTrustDrPeterMacCallumSeniorLecturerinHaematology,BartsandTheLondonSchoolofMedicineandDentistry,QueenMaryUniversityofLondonHonoraryConsultantHaematology,BartsHealthNHSTrust.JohnRobsonReaderandGP,BartsandtheLondonSchoolofMedicineandDentistry,QMULDrShabanaAliGPPrincipalSouthdeneSurgery/GPwSICardiologyClinicalDirectorRedbridgeCCGDrHarjitSinghGPPrincipalGranvilleMedicalCentre/GPwSICardiologyClinicalDirectorRedbridgeCCGPreetiSudUCLPartnersPartners:

Thisguidedetailsthestepsrequiredtoassessapatientwithatrialfibrillation(AF)andthedifferentaspectstoconsiderbeforeinitiatinganticoagulationforstrokeprevention.Figure1summarisesthepatientpathwayandthecontentofthisguide.Steps1to6detailthedifferentstagesinvolvedwhenapatientisdiagnosedwithAF,followedbystep7withadditionalinformationonhowtofurtherreducetheriskofstrokebyaddressingothercardiovascularriskfactors.Figure1:PatientPathway

PerioperativemanagementofNOACtherapy

AFDiagnosis

Anticoagulationinitiation

Monitoring&followup

Confirmatrialfibrillationdiagnosis

Assessriskofstrokeandbleeding

Initialclinicalevaluation

Startananticoagulant

NOAC Warfarin

Followup OngoingINRchecks

Anticoagulationclinicinitiation

Patientcounselling

1

2

3

4

5

68

Optimisetherapyfor

bloodpressure,lipid

control

7

1. ConfirmAtrialFibrillationDiagnosis

Screening:30secondpulsecheckAllpatientsover65shouldhavetheirpulseroutinelycheckedevery5years

andannuallyiftheyhaveamajorlongtermconditionwithincreasedCVDrisk

ifirregularpulse*

Diagnosis:12leadECGIdentifythenatureoftheirregularpulseincludingAF

IfparoxysmalAFissuspected,a24hourambulatoryECGmonitorshouldbeused.

*AmobileECGdevicesuchastheAlivecorKardiacanbeusedtocheckapulseorcheckamanuallydetectedpulseirregularity.Ifanabnormalityisconfirmedthepatientwillstillrequirea12ledECG.MoreinformationonhowtouseAlivecorKardiacanbeaccessedon:https://www.alivecor.com/

2. ClinicalEvaluation

Atrialfibrillationisthemostcommoncardiacarrhythmiawithaprevalenceof1-2%inEngland.Prevalenceincreaseswithageandisuncommonunder65yearsbutbytheageof85yearsitincreasesto1in8peopleandisamajorcauseofstroke.

• AFmaybeasymptomatic,butwhensymptomatic,patientsmaypresentwith:

o Palpitationso Dizziness/syncopeo Fatigueo Faintingo Breathlessness/dyspnoea

• InvestigatefactorstriggeringAF;suchasinfection,alcohol,caffeine,exercise,familyhistory,

thyroiddiseaseorassociatedcardiovasculardisease.

• Orderanechocardiogramifyoususpectheartfailure,structuralheartdisease,valvularheartdisease.

• Orderthefollowingbaselinebloodtests:

o Fullbloodcounto Clottingscreen(includingINR)o Liverfunctiontestso Ureaandelectrolyteso Thyroidfunctiontests(toexcludeanyunderlyingthyroiddiseasewhichmaybe

causingpalpitations)

TIP:DosingofNOACsisbasedonCrClusingCockroftandGaultEquation;

NOTeGFR.

3. AssessingRiskofStrokeandBleeding

AFpatientsarefivetimesmorelikelytodevelopastrokeincomparisontosomeonewithnormalheartrhythm.UsetheCHA2DS2-VAScscoretoriskassessallthefollowingtypesofAFwhichmayrequireanticoagulation,theriskfactorsarelistedintable1:1

- Paroxysmal- Persistent- Permanent- Atrialflutter- Acontinuingriskofarrhythmiarecurrenceaftercardioversionbacktosinusrhythm

Table1:CHA2DS2-VAScscore2Riskfactors Definition Score

Congestiveheartfailure

Thepresenceofsignsandsymptomsofeitherrightorleftventricularfailureorboth,confirmedbynon-invasiveorinvasivemeasurementsdemonstratingobjectiveevidenceofcardiacdysfunction.Leftventricularejectionfraction<40%.

1

Hypertension Arestingbloodpressure>140mmHgsystolicand/or>90mmHgdiastoliconatleast2occasionsOrcurrentantihypertensivepharmacologictreatment

1

Age>75 2Diabetesmellitus Fastingplasmaglucoselevel>7.0mmol/L(126mg/dL)

Ortreatmentwithoralhypoglycaemicagentand/orinsulin1

Stroke/TIA/Thromboembolism

2

Vasculardisease Priormyocardialinfarction,anginapectoris,percutaneouscoronaryinterventionorcoronaryarterybypasssurgery.Presenceof:intermittentclaudication,previoussurgeryorpercutaneousinterventionontheabdominalaortaorthelowerextremityvessels,abdominalorthoracicsurgery,arterialandvenousthrombosis.

1

Age65-74 1Sexfemale 1

Maximumscore 9Patientsshouldbemadeawareoftheirrisksofstrokewhichisrepresentedintable2andwhatmeasurecanpreventthis.

QOFindicator:CHA2DS2-VAScscorecalculation

Table2:Whatisthepatients’riskofstroke?

CHA2DS2-VAScscore Adjustedstrokerate(%/year)

0 -1 1.3%2 2.2%3 3.2%4 4.0%5 6.7%6 9.8%7 9.6%8 6.7%9 15.2%

AnticoagulationshouldbeofferedtopatientsbasedontheirCHA2DS2-VAScscoreasoutlinedinfigure2.Figure2:CHA2DS2-VAScscoredeterminestheneedforanticoagulation

ParoxysmalAFandfluttershouldbetreatedinthesamewayaspermanentorpersistentAFwithconsiderationofanticoagulationinmalesifCHA2DS2-VAScscoreis1.MalesandfemaleswithaCHA2DS2-VAScscoreof2oraboveshouldbeofferedanticoagulation(unlessthereisacontraindication).BleedingandothercontraindicationsIfthereisahistoryofgastro-intestinalbleeding,intracerebralbleeding,clottingabnormalityordruginteraction,anticoagulationshouldbediscussedwithahaematologist.TheHASBLEDscoreassessestheriskofbleedinginpeoplewhoarestartingorestablishedonanticoagulationaslistedintable3.Thisscoreisnotusedtoidentifypeoplecontraindicatedforanticoagulation;howeveritmayhighlightfactorsthatcanbemodifiedtoreducetheriskofbleeding.

TIP:CautionisadvisedforpeoplewithHASBLEDscoreof>3andmayrequirefrequentmonitoring

butdoesnotindicateacontraindicationtoanticoagulation.

CHA2DS2-VAScscore

NoAnticoagulanttreatmentrequired

ConsiderAnticoagulationEducatepatientsonrisks

OfferAnticoagulationEducatepatientsonrisks

0ifmaleor1iffemale 1ifmale≥2inanypatient

Table3:HAS-BLEDscore2

Riskfactors Definition ScoreHypertension Uncontrolled,if>160mmHgsystolic 1Abnormalliverfunction

Cirrhosisorbilirubin>2xnormalAST/ALT/ALP>3xnormal

1

Abnormalrenalfunction

Dialysis,transplant,Cr>200µmol/L 1

Stroke Previoushistory,particularlylacunar 1Bleeding Bleedinghistoryorpredisposition(anaemia) 1LabileINRs (Patientsonwarfarin)Therapeutictimeinrange<60% 1Elderly Age>65 1Drugs AntiplateletagentsorNSAIDs 1Alcohol Alcoholuse>8units/week 1

Maximumscore 9

4. StartanAnticoagulantDonotofferantiplatelet(i.e.aspirin)monotherapyforstrokepreventionastheriskreductionofstrokeisinsignificantandthebleedingprofileiscomparabletothatofanticoagulants.3Referthefollowinggroupsofpatientstoananticoagulationclinicforinitiation(alsorefertotable1):

- Aged<18years- Renalimpairment(creatinineclearance<30ml/minute)- Uncontrolledseverehypertension>160mmHgsystolic- Thoseonchemotherapyformalignanttumours- Pregnancy- Liverfailure- Gastrointestinalbleedofsignificance- Organbiopsywithinthelast4weeks- Unexplainedanaemia- Alcoholdependence- Livercirrhosis- Mechanicalheartvalve- Valvularheartdisease- Previousintracerebralhaemorrhage- Antiplatelettherapywhichcannotbestopped- Aknownhereditaryoracquiredbleedingdisordere.g.Haemophilia- Patientweightabove120kg- Recentacutecoronarysyndromerequiringadualantiplatelettherapy- Warfarininitiation;unlesstheprimarycareorganisationissetuplocallytoinitiatethis

QOFindicator:CHA2DS2-VAScscore>2&onanticoagulationtherapy

Educatethepatientonthedifferentanticoagulantagentsavailable;vitaminKantagonistssuchaswarfarinortheNOACssuchasapixaban,dabigatran,edoxabanandrivaroxaban.Discusstheoptionswiththepatientandbasethechoiceontheirclinicalfeaturesandpreferences.Usethetable4,5andfigure3toassistinthisjointdecisionmakingprocess.Table4:DifferencesofwarfarinandNOACs Warfarin NOACOngoingMonitoring INR Renalfunction,LFT,FBCDosing Variable ConstantdoseInteractions Dietary&Medicines MedicinesBleedingprofile Higherriskofintracranial

haemorrhageHigherriskofgastrointestinalhaemorrhage

Table5:DifferencesbetweentheNOACs

Apixaban Dabigratran Edoxaban RivaroxabanDosing Twicedaily Twicedaily Oncedaily OncedailyDosetteBox Suitable NOTsuitable Suitable SuitableIntakewithfood No No No MandatoryLactoseintolerance NOTsuitable NOTsuitable Suitable NOTsuitableAntidote None available None NoneAvoidwhenCrCloflessthan

15ml/min 30ml/min 15ml/min 15ml/min

Extremebodyweights:Specialistconsultation

<50kgOr>120kg

TIP:DosesanddoseadjustmentsforNOACsaredifferentforpatientstreatedforother

indicationssuchasvenousthromboembolism.NOACdosesforAFarelistsinfigure4.

TIP:PatientsthataresuppliedwarfarinorNOACsfromtheiranticoagulationclinicorpharmacyratherthanGP,shouldbecoded

annuallyasfollows:- ‘Anticoagulationprescribedbythirdparty’;- Recordwarfarinonprescribingsystemsoitwillappearon

summarycarerecordbutnotissued

ForNOACs;prescribeonemonthsupplyandendorsetheprescriptionwith‘NMS’.Thisnewmedicinesservice(NMS)endorsementwillindicatethecommunitypharmacytosupportthepatientseducationonthenewlyprescribedanticoagulant,specificallysupportingadherence.Thisserviceallowsthepatienttobeinvitedontwooccasionswithinthefirstmonthsforinitiationtodiscussanypharmaceuticalissueswiththepharmacist.Thereafter,on-goingsupportforthepatientcanbeconductedannuallyviathemedicineusereviewservice.Potentialfordrug-druginteractionswithNOACsStrong inhibitors of CYP3A4 and P-glycoprotein or inducers of CYP3A4 can have significantinteractionswithNOACs,whichshouldeitherbeavoidedoradoseadjustmentfortheNOACmayberequired.RefertoSummaryofProductCharacteristics(SPC)forfurtherinformation.BelowisalistofcommoninteractionswithNOACs:StronginhibitorsofP�glycoproteinandCYP3A4(Avoidconcurrentuse)- Azoleantifungals(e.g.,itraconazole,ketoconazole,posaconazole,andvoriconazole)- HIVproteaseinhibitors(e.g.,darunavirfosamprenavir,indinavir,lopinavirnelfinavir,ritonavir,

andsaquinavir)

StronginducersofP�glycoprotein(Avoidconcurrentuse)- Carbamazepine- Phenobarbital- Phenytoin- Rifampin- St.John’sWortInhibitorsofP�glycoproteinand/orCYP3A4(usewithcaution)-Amiodarone-Diltiazem,Verapamil-Ticagrelor-Azithromycin,erythromycin,clarithromycin-Tamoxifen-Grapefruit(fruitorjuice)

Figure4:DosingofNOACsforAtrialFibrillation(AF)

<15ml/min

Not recommended

Patienthasrisk factorforstroke

EstimateCrCl

15–49ml/min*

15mgod

≥50ml/min

20mgod

Rivaroxaban

2.5mgbid 2.5mgbid 5mgbid

Apixaban Patienthasriskfactorforstroke

EstimateCrCl <15ml/min 15–29

ml/min ≥30ml/min

Checkage Checkweight

Checkserum creatinine

≥80years ≤60kg ≥133µmol/l

If≥2features

if≤1features

Notrecommended

Edoxaban Patienthasrisk factorforstroke

EstimateCrCl

<15ml/min

15–50ml/min >50ml/min

Not recommended 30mgod

30mgod 30mgod

60mgod

≤60kg PotentP-gp inhibitors

1.RivaroxabanSmPC;2.ApixabanSmPC;3.DabigatranSmPC;4.EdoxabanSmPC

Patienthasriskfactorforstroke EstimateCrCl

<30ml/min 30–50ml/min >50ml/min

Age >80years Age <75years Age 75–80years Age >80years

Contraindicated

Low thromboembolic riskandhigh bleedingrisk

110mg bid 110mg bid

150mg bid

150mg bid

110mg bid

150mg bid

110mg bid

Dabigatran

Age≥75yearsorhighrisk

ofbleeding

5. Patientcounselling

Useacounsellingchecklisttogothroughallthekeypointswiththepatientbeforestartinganticoagulation(seeappendix1asanexample).Tosupportpatienteducation,patientinformationbookletsonNOACsareavailablefromthemanufactures,thecontactsarelistedintable6.

Table6:ContactdetailsfororderingpatienteducationmaterialforNOACsNOAC Manufactureswebsites Contactforbookletordering

(Medicinesinformationdepartment)Apixaban https://www.eliquis.co.uk/ 01895523740Dabigatran https://www.pradaxa.co.uk/ 01344742579Edoxaban http://www.lixiana.co.uk/ 01753482771Rivaroxaban http://www.xarelto-info.co.uk/ 01635563000

Signpostingpatientsformoreinformationonatrialfibrillation

ArrhythmiaAlliance:http://www.heartrhythmalliance.org/aa/ukAtrialFibrillationassociation:http://www.heartrhythmalliance.org/afa/uk

6. Followup

6.1 Warfarin

RegularmonitoringofINRinananticoagulationclinicwillbecarriedout,atleastevery12weekswhenwarfarinisstabilised.Ifpooranticoagulationcontrolcannotbeimproved,therisksandbenefitsofalternativestrokepreventionstrategiesshouldbereassessedanddiscussedwiththepatient.Pooranticoagulationisdefinedas:

- 2INRvalueshigherthan5or1INRvaluehigherthan8withinthepast6months- 2INRvalueslessthan1.5withinthepast6months- Timeintherapeuticrange(TTR*)lessthan65%

*TTR:TimeinTherapeuticRangecalculatedwithavalidatedmethodofmeasurementsuchastheRosendaalmethod.

6.2 NOAC

Aonemonthfollow-upafterNOACinitiationisrecommendedtoreviewaslistedintable7.Table7:ChecklistforAnticoagulationFollow-upChecklistfollow-up Interval Comments

1. Adherence 1monththenateachvisit

Instructpatienttobringremainingmedication:assessthenumberofmisseddoses,noteandcalculateaverageadherence

Re-educateonimportanceofstrictintakeschedule

Informaboutadherenceaidsandsupport(specialboxes,smartphoneapplications,referraltoMedicineUseReview)

2. Thromboembolism 1monththenateachvisit

Systemiccirculation(TIA,stroke,peripheral)

Pulmonarycirculation

3. Bleeding 1monththenateachvisit

“nuisance”bleeding,bleedingwithimpactonqualityoflife:preventivemeasurespossible?(PPI,haemorrhoidectomy,etc.)

Motivatepatienttodiligentlycontinueanticoagulation

4. Sideeffects 1monththenateachvisit

AssessrelationwithNOACanddiscusswithpatientstodecidecontinuation(throughmotivation),changewithanotheranticoagulantdrugortemporarycessation(withbridging).

5. Co-medication 1monththenateachvisit

Reviewpossibleinteraction(prescriptiondrugs,over-the-counterdrugsespeciallyNSAIDsandaspirin,herbalproducts)

6. Bloodsampling

Yearly6-monthlyx-monthly

Haemoglobin,renalandliverfunctions

Generalpopulationif>75-80years(especiallyifonapixabanordabigatran)ifimpairedrenalfunctionCrCl<60ml/min:recheckinterval(x)=CrCl/10

TIP:Thefrequencyoftestingrenalfunctionisdeterminedbybaselinerenalbloodusingthefollowingequation:

Creatinineclearance(CockroftandGaultEquation)=Xmonths10(TheCockroftandGaultequationisavailableonthe‘NOACtemplate’onEMISsystems)

7. Optimisetherapyforbloodpressurelipidcontrol

Strokeandheartattackpreventioncanbeoptimisedbyaddressingcardiovascularriskfactorssuchashighbloodpressure,serumcholesterol,obesityandsmokingwithheart-healthylifestylechangesandmedicines.AlmostallpatientswithAFhaveQRiskCVDrisk>10%andatorvastatin20mgforprimarypreventionandatorvastatin40mg(or80mg)forsecondarypreventionareadvised.

7.1Hypertension

HypertensionisastrokeriskfactorinAF;uncontrolledhighbloodpressureincreasestheriskofstrokeandbleedingeventsandmayleadtorecurrentAF.Hypertensionshouldbecontrolledto<140/90mmHg(orlowerifassociatedrelevantco-morbiddiabetes,strokeorCKD).Hence,bloodpressurehastobecheckedregularlyandtreatedappropriatelyaccordingtocurrentNICEGuidelinesCG127andCG180.

7.2Obesityandsmoking

ObesityincreasestheriskforAFwithaprogressiveincreaseaccordingtobodymassindex(BMI).Adoptinganintegratedapproach,considerraisingawarenessofservicesamonghealthandsocialcareprofessionalstosupportyourpatientwiththeirlifestyleweightmanagement.Smokersshouldbesupportedtostopsmoking.RefertoNICEGuidelinesCG434andCG1815toadviselifestylemodifications.

8. PerioperativemanagementofNOACtherapy6

Warfarin Dabigatran

Rivaroxaban

Apixaban Edoxaban

OACusewithnoclinicallyimportantbleedingrisk Dentalprocedures—outpatientdental

surgery(includingextractions)canusually

beundertakenwithouttemporarily

stoppingorreducingthedoseof

warfarin.ItisrecommendedthattheINR

ischecked72hoursbeforedental

surgery.Theriskofsignificantbleedingin

peoplewithastableINRwithintherange

of2to4isverysmall,buttheriskof

thrombosismaybeincreasediforal

anticoagulantsaretemporarily

discontinued

Surgery—ingeneral,warfarinisusually

stopped5daysbeforeplannedsurgery,

andoncetheperson'sinternational

normalisedratio(INR)islessthan1.5

surgerycangoahead.Warfarinisusually

resumedatthenormaldoseonthe

eveningofsurgeryorthenextdayif

haemostasisisadequate.

Theprocedurecanbeperformedjustbeforethenextdoseofdabigatran,rivaroxabanorapixabanisdue,orapproximately18–24hoursafterthelastdosewastaken

(treatmentshouldberestarted6hourslater).

Fordentalproceduressuchasextractionsoflessthan3teeth,considerprescribingtranexamicacid5%mouthwash;10mLasamouthwashfourtimesadayfor5days

startingonthedayoftheprocedure.

OACuseandundergoingsurgerywithalowbleedingrisk

Dabigatranshouldbestopped24hours

beforetheprocedure.

Ifthepersonhascreatinineclearance50–

80mL/mindabigatranshouldbestopped

36hoursbeforetheintervention

Ifthepersonhascreatinineclearance30–

50mL/mindabigatranshouldbestopped

48hoursbeforetheintervention

Rivaroxabanshouldbestopped24

hoursbeforetheprocedure.

Ifthepersonhasacreatinineclearance

between15–30mL/minrivaroxaban

shouldbestopped36hoursbeforethe

procedure.

Apixabanshouldbestopped24hours

beforetheprocedure.

Ifthepersonhasacreatinine

clearancebetween15–30mL/min,

apixabanshouldbestopped36hours

beforetheprocedure.

Edoxabanshouldbestopped24hours

beforetheprocedure.

OACuseandundergoingsurgerywithahighbleedingrisk

Dabigatranshouldbestopped48hours

beforetheprocedure.

Ifthepersonhascreatinineclearance50–

80mL/mindabigatranshouldbestopped

72hoursbeforetheintervention

Ifthepersonhascreatinineclearance30–

50mL/mindabigatranshouldbestopped

96hoursbeforetheintervention

Rivaroxabanshouldbestopped48

hoursbeforetheprocedure.

Apixabanshouldbestopped48hours

beforetheprocedure.

RestartingOACsaftersurgery

Seelocalguidelines.Treatmentshouldberestartedassoonaspossibleaftertheprocedureorsurgicalinterventionprovidedtheclinicalsituationallowsandadequatehaemostasishasbeenestablishedasdeterminedbythetreatingphysician.OnsetofactionofNOACsismuchfasterthanthatofwarfarin.

NOCLINICALLYIMPORTANTBLEEDINGRISK

DENTALINTERVENTIONSSUCHAS;EXTRACTIONOF1TO3TEETH,

PERIODONTALSURGERY,INCISIONOFABSCESSANDIMPLANT

POSITIONING.CATARACTORGLAUCOMAINTERVENTIONS.�

ENDOSCOPYWITHOUTSURGERY.�MINORSURGERY(E.G.ABSCESSINCISIONANDSMALL

�DERMATOLOGICEXCISIONS).�

SOMEEXAMPLESOFSURGERYWITHLOWBLEEDINGRISKENDOSCOPYWITHBIOPSY.�

PROSTATEORBLADDERBIOPSY.�

ELECTROPHYSIOLOGICALSTUDYORRADIOFREQUENCYCATHETERABLATIONFOR

SUPRAVENTRICULARTACHYCARDIA(INCLUDINGLEFT-SIDEDABLATIONVIASINGLE

TRANS-SEPTALPUNCTURE).�

ANGIOGRAPHY.�

PACEMAKERORIMPLANTABLECARDIOVERTERDEFIBRILLATOR�(ICD)IMPLANTATION

(UNLESSCOMPLEXANATOMICALSETTING,E.G.CONGENITALHEARTDISEASE).�

SOMEEXAMPLESOFSURGERYWITHHIGHBLEEDINGRISKCOMPLEXLEFT-SIDEDABLATION(PULMONARYVEINISOLATION;VTABLATION).

SPINALOREPIDURALANAESTHESIA.�

LUMBARDIAGNOSTICPUNCTURE.�

THORACICSURGERY.�

ABDOMINALSURGERY.�

MAJORORTHOPAEDICSURGERY.�

LIVERBIOPSY.�

TRANSURETHRALPROSTATERESECTION.�

KIDNEYBIOPSY.�

Anticoagulationcounsellingchecklist

Patientname:………………………………………………………………………. Date:……………………………………

Prescribedtreatment:……………………………………………………………

Commonchecklistforalloralanticoagulants¨ Treatmentindicationandmodeofaction:AF,makesbloodlesssticky,takeslongertoclot

¨ ReasonstoinitiateanOAC:preventionofstrokeandotherthromboembolismevents

¨ Durationoftreatment:dependsontheconditionbeingtreated–AFtreatmentisgenerallylifelong.

¨ Possibleadverseevents(bruising,bleeding)andappropriateactionsaccordingtoseverity:

o Minorbleedswhilstbrushingteethorgums,morebruisingthanusual;quitenormalifnotrecurrent

o Majorbleedsifnosebleedlongerthan10mins,recurrentbleedsinurineorstools;seekhealthprofessional

advices

¨ Useofinformationbookletandalertcard:hastocarryalertcardinallcircumstances

¨ Informallhealthcarestaff:Physicians,Pharmacist,Dentistabouttheanticoagulanttreatment

¨ Newprescribeddrugs/self-prescribeddrugs/over-the-counterdrugswithpotentialfordrug

interactions:avoidNSAIDsandaspirin/preferparacetamol.

¨ Explanationsabouttheprescribeddoseandhowtotakemedicine:aimtotakeatthesametimeeach

day

¨ Hobbiesandleisureactivities:avoidcontactsportsandotherhigherrisksports,asincreasedriskof

bruising/bleeding

¨ Travels:alwaystakeprescriptionandalertcard

¨ Healthcareprofessionalsupport:givenamesandcontactsincaseofadverseevents

SpecifickeypointsforNOACsapixaban,dabigatran,edoxaban,rivaroxaban

¨ Tabletregimen:dose,frequency,rivaroxabanwithfoodtoimproveabsorption

¨ Importanceofadherence:risk(i.e.shorthalf-lifeandlossofefficacyifpoorlycompliant)andreminders(i.e.

specialboxes,smartphoneapps)

¨ Misseddose:aforgottendoseofdabigatranorapixabancanbetakenupuntil6hoursafterthescheduledintake

whereasaforgottendoseofrivaroxabanoredoxabancanbetakenupuntil12hoursafterthescheduledintake

¨ Associatedbloodtestsandfrequency:liverandkidneyfunction(generallyyearlyunlessimpairedrenal

function)

¨ Specificpossiblesideeffects:GIdisruption(dabigatran),itching,bleeding

¨ Normaldietandnointeractionwithalcohol

¨ ProandconscomparedtowarfarinforAF,NOACareaseffectiveaswarfarinforthepreventionofstrokeand

systemicembolism,withasimilarrateofmajorbleeding,butwithalowerriskofintracranialhaemorrhage

¨ Contraception,pregnancy,andhormonereplacementtherapy(ifrelevant):womenshouldnot

becomepregnantnorbreastfeedwhilsttakingNOACs,reliablecontraceptionisrequired

Patienttosignthistoagreehe/sheunderstandsthecontentsofthischecklist.Patient/advocate/representativePrintname:Signature:Date:

Thepatientmustreceiveapatientinformationbookletandpatientalertcard.ThealertcardMUST

befullycompletedandthepatientadvisedtokeepitwithhim/heratalltimes.

Appendix1

1AtrialFibrillation:Management,NICEClinicalguideline[CG180],UpdatedAugust2014

2https://www.chadsvasc.org

3MantJ,HobbsFDR,FletcherK,etal.Warfarinversusaspirinforstrokepreventioninanelderly

communitypopulationwithatrialfibrillation(theBirminghamAtrialFibrillationTreatmentofthe

AgedStudy,BAFTA):arandomisedcontrolledtrial.Lancet2007;370:493–503.

4Obesityprevention,NICEClinicalguideline[CG143],UpdatedMarch2015.

5Cardiovasculardisease:riskassessmentandreduction,includinglipidmodification,NICE

Clinicalguideline[CG181],UpdatedSeptember2016.

6CommonQuestionsandAnswersonthePracticalUseofOralAnticoagulantsinnon-

ValvularAtrialFibrillation,UKMI,October2014.