European Primary Care Cardiovascular Society (EPCCS) consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care

Abstract

Background: Atrial fibrillation affects 1-2% of the general population and 10% of those over 75, and is responsible for around a quarter of all strokes. These strokes are largely preventable by the use of anticoagulation therapy, although many eligible patients are not treated. Recent large clinical trials have added to the evidence base on stroke prevention and international clinical guidelines have been updated.

Design: Consensus practical recommendations from primary care physicians with an interest in vascular disease and vascular specialists.

Methods: A focussed all-day meeting, with presentation of summary evidence under each section of this guidance and review of European guidelines on stroke prevention in atrial fibrillation, was used to generate a draft document, which then underwent three cycles of revision and debate before all panel members agreed with the consensus statements.

Results: Six areas were identified that included how to identify patients with atrial fibrillation, how to determine their stroke risk and whether to recommend modification of this risk, and what management options are available, with practical recommendations on maximising benefit and minimising risk if anticoagulation is recommended and the reasons why antiplatelet therapy is no longer recommended. The summary evidence is presented for each area and simple summary recommendations are highlighted, with areas of remaining uncertainty listed.

Conclusions: Atrial fibrillation-related stroke is a major public health priority for most health systems. This practical guidance can assist generalist community physicians to translate the large evidence base for this cause of preventable stroke and implement this at a local level.

Keywords: Atrial fibrillation; anticoagulation; bleeding risk; stroke prevention; stroke risk.

Figure 1.

Percent of patients free from stroke over time, stratified by time spent in therapeutic range (INR 2.0–3.0). Adapted from Gallagher et al., Thromb and Haem 2011.

Figure 2.

Flow chart of recommendations. Management of stroke prevention in atrial fibrillation as recommended in this document. Strength of recommendations is indicated by colour, with recommendations that should be used in green, and interventions that may be considered in blue. See text for explanation of HAS-BLED and CHA₂DS₂-VASc scores. AF: atrial fibrillation; OACs: oral anticoagulants; NOACs: novel oral anticoagulants; ASA: acetyl salicylic acid; VKA: vitamin K antagonists.