Presentation by Dr Debbie Lowe, Clinical Lead - Stroke, Getting It Right The First Time: Getting it right first time at The future of innovation in AF and stroke prevention in the NWC, 27 June 2018, Haydock Park Racecourse

1. Why is AF a priority?
The reality of AF related Stroke
Dr Deb Lowe
National Clinical Lead for Stroke Medicine – NHSI GIRFT Programme
North West Coast Strategic Clinical Network - Stroke Lead
Stroke Physician & Geriatrician
Wirral University Teaching Hospital NHS Foundation Trust

2. Disclosures
• This is not a sponsored talk
• Previously I have received sponsorship / honoraria for
delivering educational sessions from Bayer, Pfizer and
Boehringer-Ingelheim

3. The burden of atrial fibrillation (AF) in the UK
983,300 people
have ‘GP
registered’ AF in
the UK1
AF increases
your risk of
stroke by five
times2
422,600 people
are thought to be
living with AF
undiagnosed1
Almost double the
risk of having AF if
you are a man, which
could lead to a stroke3
AF-related
strokes in
women are
more
devastating4
The cost saving of
preventing one AF-related
stroke through the use of
anticoagulants is £11,9007
Approx 50% uptake
of anticoagulants is
low7
Treatment of AF with
anticoagulants reduces risk
of stroke by up to 70%6
AF prevalence
increases with age
and occurs in 6% of
the over 65 population5
1. Size of the prize in cardiovascular disease (CVD) prevention. PHE /NHSE . http://www.bmj.com/content//344/BMJ.E4181. 2. Wolf PA, et al. Stroke 1991;22:938-98; 3. Schnabel RB, et
al. Lancet. 2009 February 28; 373(9665): 739–745. 4. Friberg J, et al. The American Journal of Cardiology. 2004;94(7):889-894; 5. Feinberg WM et al. Arch Intern Med. 1995;155:469-473;
6. NHS East Midlands Clinical Senate Strategic Clinical Networks. Available at: http://www.emsenatescn.nhs.uk/strategic-clinical-networks/cardiovascular-disease-home/stroke-prevention-
in-atrial-fibrillation/. Last accessed March 2017; 7. NHS Improvement. Commissioning for Stroke Prevention in Primary Care – The Role of Atrial Fibrillation (2009). Available at:
http://www.atrialfibrillation.org.uk/files/file/AF_Commissioning_Guide.pdf. Last accessed March 2017.

4. • At ≥40 years of age, the remaining lifetime risk for developing AF is
~1:4
• 26.0% for men
• 23.0% for women
• Lifetime risks for AF are high (1 in 6), even in the absence of
antecedent congestive heart failure or myocardial infarction (MI)
• 16.3% for men
• 15.6% for women
Lifetime risk of developing AF is approximately 25%1
1. Lloyd-Jones DM, et al. Circulation 2004;110:1042.

5. Relationship between AF and stroke
Source: QoF 2015

6. Stroke in the UK
Population ~ 60million:
• Approximately 110,000 strokes each year
• 2016: 12,500 secondary to AF, only 7,100 on
anticoagulation (SSNAP)
• 35,000 stroke deaths each year, 11% of all deaths
• Over 900,000 people living in England who have
had a stroke
• 1 million living with AF
• 250,000 disabled stroke survivors

7. The burden of stroke
• 5 million deaths world wide annually
• Stroke affects 0.2% of entire population
• 3rd most common cause of death (12% of all deaths)
after coronary heart disease & cancer
• Stroke costs NHS and economy £8.9 billion a year
(direct costs to NHS £4.5 billion)
• Largest single cause of adult disability
• Higher mortality & incidence in lower social class
groups

8. Outcome after stroke
• About 25% will die within 1 month
• 90% stroke deaths are >65yrs
• By one year:
Dead - 30%
Dependent - 25%
Moderate /Severe disability – 50%
• After first stroke, 10% will have another stroke in the
first year, and 5% per year thereafter
• Increased risk of MI / ‘vascular event’ following stroke

9. Cardio-embolic Stroke:
Middle Cerebral Artery Occlusion

10. Copenhagen stroke study1
Scale Outcome measure Patients
with AF
Patients
without AF
SSS Initial stroke severity
Neurological outcome*
Lower score =
greater neurological
impairment
30
46
38
50
BI Initial disability
Functional outcome*
Lower score =
greater disability
35
67
52
78
Length of hospital stay (days) 50 40
In-hospital mortality (%) 33 17
Discharged to nursing home (%) 19 14
Discharged to own home (%) 48 69
*At discharge
SSS = Scandinavian Neurological Stroke Scale; BI = Barthel Index.
Stroke in patients with AF is more severe than in those without AF
AF patients face an increased risk of recurrent stroke2
1. Jørgensen HS et al. Stroke 1996;27:1765-1769; 2. Marini C et al. Stroke 2005;36:1115.

11. Outcome data for patients with prior AF
This is a bespoke report for this 12 month period, Oct 2014 – Nov 2015
Number of AF strokes
NOT on anticoag prior to arrival
Number of AF strokes Percentage of patients with known AF
before stroke who had not been
prescribed anticoagulation prior to
their stroke
England 8572 15274 56.1
AF strokes not on anticoagulation (patients discharged from inpatient
care)
Number of AF
strokes NOT on
anticoag prior to
arrival
Number with
modified Rankin
of 0 at discharge
Number with
modified Rankin
of 1 at discharge
Number with
modified Rankin
of 2 at discharge
Number with
modified Rankin
of 3 at discharge
Number with
modified Rankin
of 4 at discharge
Number with
modified Rankin
of 5 at discharge
Number with
modified Rankin
of 6 at discharge
(died in hospital)
8572 630 1042 1023 1382 1439 944 2112
Source – https://en.wikipedia.org/wiki/Modified_Rankin_Scale https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx

12. • Functional outcomes of stroke are significantly worse in patients with
AF, and more patients remain bedridden
The impact of AF on stroke outcomes1
1. Dulli DA, et al. Neuroepidemiology 2003;22:118.
41.20%
23.70%
0%
10%
20%
30%
40%
50%
With AF (n=194) Without AF (n=867)
Patientsbedriddenonadmission(%)
OR for bedridden state following stroke
due to AF was 2.23 (95% CI: 1.87, 2.59)
p<0.0005

13. Strokes caused by AF have much higher
morbidity and mortality

14. Quality Improvement in Stroke
• Huge achievements since National Stroke
Strategy in 2007
• Improved performance in SSNAP across the
country since 2012
• So much more to do……….

15. Reduction in 30-day mortality from
acute stroke 1998-2014
50%

16. Reduction in hospital length of stay
for acute stroke 2001-2014
49%

17. Decline in institutionalisation for
acute stroke 2004-2013
46%

18. Conditions and lifestyle characteristics identified
as a risk factors for stroke:
High blood pressure High Cholesterol
Atrial fibrillation Diabetes mellitus
Smoking Obesity
Carotid artery disease Heavy alcohol use
Myocardial infarction Physical inactivity
Obstructive sleep apnoea Hyperhomocysteinaemia
Modifiable Vascular risk factors

19. A tidal wave
of cardio-
embolic
stroke
Age-Specific Incidence, Outcome, Cost, and Projected
Future Burden of Atrial Fibrillation–Related Embolic
Vascular Events A Population-Based Study Gabriel S.C.
Yiin, Dominic P.J. Howard, Nicola L.M. Paul, Linxin Li,
Ramon Luengo-Fernandez, Linda M. Bull, Sarah J.V.
Welch, Sergei A. Gutnikov, Ziyah Mehta and Peter M.
Rothwell and on behalf of the Oxford Vascular Study
Circulation, 2014
+ 220%
+90%

20. Prevalence of AF predicted to more than double by 2050
0
8
10
12
16
2050
PeoplewithAFintheUS(millions)
Year
2000 2010 2020 2030 2040
6
4
2
Projected incidence of AF assuming no further
increase in age-adjusted incidence
Projected incidence of AF assuming a continued
increase in age-adjusted incidence as evident in
1980–2000
14

21. AF patients face an increased risk of
recurrent stroke1
Months after first stroke
Cumulativeprobabilityofrecurrence(%)
10
12
Patients with AF (n=869)
Patients without AF (n=2,661)
8
6
4
2
0
0 2 4 6 8 10
p=0.0398
1. Marini C, et al. Stroke 2005;36:1115.

22. 70%
Copenhagen stroke study, a prospective community-based study. n=1,197
**In hospital mortality: 72 deaths, n=217 with AF vs. 171 deaths n=968 without AF
†Discharge to own home: n=104 with AF vs. 662 deaths n=968 without AF
‡Length of hospital stay: 50.4 days with AF vs. 39.8 days without AF
Jorgensen, et al. Stroke 1996;27:1765-9
Among patients who have had a stroke, those with AF experienced:
increase in in-hospital mortality**
40%
decrease in the relative
chance of discharge to
own home†
20%
increase in the length of
hospital stay‡
…compared to those without AF
AF Related Strokes Are More Severe

23. Healthcare costs of AF related stroke
• AF alone accounts for more than 1% of healthcare expenditure in the UK
(NHS England)
• 30-day mortality rate of ~33% (vs 16% for non-AF strokes)1
• 1-year mortality rate of ~50% (vs 27% for patients without AF)1
• Total costs for treating the 12,500 strokes in England that are attributable
to AF is £148 million in the first year
• Stroke care is expensive with £2.2 billion annual NHS costs, plus the
additional burden of social care (NHS England)
1. Marini et al. Stroke. 2005;36:11

24. 1. Xu X-M et al. ESJ 2017:3(1):82–91.
Economic burden of stroke care to NHS is considerable1
An individual patient simulation model was built to estimate health and social care costs at one and five years after
stroke, and the cost-benefits of thrombolysis and early supported discharge. The results were illustrated using data on
all patients with stroke included in Sentinel Stroke National Audit Programme from April 2015 to March 2016 (n=84,184).
£
£
£
• Older age
• Increasing stroke severity
• Intracerebral haemorrhage stroke

25. The cost of stroke to health and social care1
1. State of the Nation Stroke statistics – January 2017. Available at:
https://www.stroke.org.uk/sites/default/files/state_of_the_nation_2017_final_1.pdf. Last accessed March 2018.

26. Julie, age 44

27. Assessing stroke and bleeding risk
CHA2DS2–VASc Score
Congestive heart failure/LV
dysfunction
1
Hypertension 1
Aged ≥75 years 2
Diabetes mellitus 1
Stroke/TIA/TE 2
Vascular disease (prior MI, PAD or
aortic plaque)
1
Aged 65–74 years 1
Sex category (i.e. female gender) 1
Maximum score 9
1. Camm J et al. Eur Heart J 2010;31: 2369-2429; 2. Pisters R et al. Chest 2010;138(5):1093-1100.
HAS-BLED Score
Hypertension (uncontrolled) 1
Abnormal Liver/Renal Function 1 each
Stroke History 1
Bleeding Predisposition 1
Labile INRs 1
‘Elderly’ (Age >65) 1
Drugs/Alcohol Usage 1 each
Maximum score 9
Assessing stroke risk1 Assessing bleeding risk2
Score of 3 or above = high bleed risk

28. High
bleeding
risk
Low
bleeding
risk
HR 0.26–0.72
‘OAC’ refers to warfarin in this study
1. Friberg L et al. Circulation 2012;125:2298.
CHA2DS2–VASc 0-2 p CHA2DS2–VASc ≥ 3 p
HAS-BLED≥3pHAS-BLED≥0-2p
Riskforintracranialbleeding
Risk for embolic stroke
ProportionsurvivingProportionsurviving
0 1 2 3 4
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3 4
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3 4
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3 4
0.0
0.2
0.4
0.6
0.8
1.0
OAC
No OAC
OAC
No OAC
OAC
No OAC
OAC
No OAC
p<0.00001
(n=1,787)
p<0.00001
(n=59,817)
p<0.00001
(n=53,797)
p<0.00001
(n=43,395)
YRS
YRS
All-cause mortality, strokes and intracranial bleeds are all
reduced by OAC irrespective of bleeding risk1

29. SSNAP 20171
April – July 2017
Total strokes 28,156
Known AF prior to admission 19.7%
(5,547)
On oral antiplatelets prior to
admission
19.5%
(1,038)
On oral anticoagulation prior
to admission
56.5%
(3,009)
Contraindicated to
anticoagulation
602
(11.3%)
1. Royal College of Physicians. SSNAP April – July 2017 Public Report, October 2017. Available at:
https://www.strokeaudit.org/Documents/National/Clinical/AprJul2017/AprJul2017-PublicReport.aspx. Accessed March 2018.

30. 2017 SSNAP data: % of AF patients not being
anticoagulated before hospital admission is decreasing1
5,325 patients were
identified as being in
AF prior to admission
No 36.0% 35.5% 35.1% 32.2%
No 60.5% 64.9% 65.2% 65.5%
5,325
Prior to hospital
admission:
• 65% of patients
with AF were not
on antiplatelet
medication
• 32% of AF
patients were not
on
anticoagulation
medication
‘No but’ was answered when there was a medical reason stated for not giving thrombolysis
according to the hospital
1. Royal College of Physicians. SSNAP April – July 2017 Public Report, October 2017. Available at:
https://www.strokeaudit.org/Documents/National/Clinical/AprJul2017/AprJul2017-PublicReport.aspx. Accessed March 2018.

31. % of patients
56.4 to 75.4
49.2 to 56.4
43.8 to 49.2
38.6 to 43.8
15.0 to 38.6
2017 SSNAP data: % of patients with known AF who had
not been prescribed anticoagulation1
% of patients with known AF before stroke
who had not been prescribed
anticoagulation prior to stroke
1. Royal College of Physicians. Outcome data for patients with prior AF, July 2017. Available at:
https://www.strokeaudit.org/Documents/National/Clinical/Apr2016Mar2017/Apr2016Mar2017-CCGAFReport.aspx. Accessed March 2018.

32. April – July 2017
England, Wales, Northern Ireland
28,156 stroke admissions
5,325 in AF (18.9%)
3.4%
53.1%
16.1%
27.4%
2017 SSNAP data: Less than 60% of AF patients were
anticoagulated at time of stroke1
OAC = Oral anticoagulant
AP = Antiplatelet
OAC + AP
OAC only
AP only
Neither
Medication prior to
admission
1. Royal College of Physicians. SSNAP April – July 2017 Public Report, October 2017. Available at:
https://www.strokeaudit.org/Documents/National/Clinical/AprJul2017/AprJul2017-PublicReport.aspx. Accessed March 2018.

33. the question is not
who we should
anticoagulate
the question is
who we should
not anticoagulate
few patients have
a CHA2DS2-
VASc=0
few patients are
ineligible for an
OAC
In practice…
Therefore…
Paradigm shift in stroke prevention in AF

34. NHS RightCare Stroke Pathway

35. NHS England size of the prize1
1. NHS Health Check. England Size of the Prize. Available at:
https://www.healthcheck.nhs.uk/commissioners_and_providers/data/size_of_the_prize_and_nhs_health_check_factsheet/. Last Accessed March 2018.

36. STP Level Size of the Prize
 Joint NHS England/Public Health England initiative to help
Sustainability and Transformation Partnerships (STPs) deliver at-scale
improvement in the secondary prevention of cardiovascular disease
1. NHS Health Check. England Size of the Prize. Available at:
https://www.healthcheck.nhs.uk/commissioners_and_providers/data/size_of_the_prize_and_nhs_health_check_factsheet/. Last Accessed March 2018.
 One-page graphic for 44 STPs
shows:
 How many people in the STP
area have undiagnosed AF
 How many have under-treated
AF
 Draws on published evidence to
calculate how many strokes
could be averted if treatment
were optimised in those who
are under-treated

37. An estimated 425,000
people may have
undiagnosed AF1
Detecting AF1
Pulse
checks
AF detection
devices
Public
awareness
Map of estimated prevalence 2015/2016
1. Health & Social Care Information Centre. Atrial fibrillation prevalence estimates. Available at:
https://www.gov.uk/government/publications/atrial-fibrillation-prevalence-estimates-for-local-populations. Accessed March 2018.

38. 926,551
1,363,321
436,770
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
Estimated and recorded cases of AF in England1
1. Health & Social Care Information Centre. QOF online results. Available at: www.content.digital.nhs.uk/catalogue/PUB18887/qof-1415-region-nation-allV1.1.xlsx. Accessed March 2017;
2. Health & Social Care Information Centre. Atrial fibrillation prevalence estimates. Available at: http://www.yhpho.org.uk//resource/view.aspx?RID=207905. Accessed March 2017.
QOF 2014/20151 NCVIN 20152 Undiagnosed AF

39. An estimated 68,000 people in
London with undetected AF!
Detected vs expected prevalence1
1. Health & Social Care Information Centre. Atrial fibrillation prevalence estimates. Available at: http://www.yhpho.org.uk//resource/view.aspx?RID=207905. Accessed March 2017.

40. Working with
Stakeholders
40

41. The Carter Report: Reducing Unwarranted Variation in
Operational Performance & Productivity in Hospitals in
England

42. …has moved from concept to an agile NHS digital
product that is improving quality and efficiency
May / June 2017 Key Stats
Total registered users 2,746
Active users (last 28 days) 942
Average weekly page hits 21,049
Average weekly logins 833
Total number of metrics 2197
GIRFT Compartments are under
development, Orthopaedics
available, Urology coming soon
The Model Hospital is a nationally
available information system
relating to metrics of productivity,
efficiency and quality of care
Model Hospital compartments are
each led by a professional
Timeline
Project initiation Feb 2016
First iteration Apr 2017
Comprehensive product Apr 2018
Users can self- select peers for
comparison
42

43. Stroke and unwarranted variation
Routinely Admitting Teams Number of patients Overall Performance Patient Centred Data Six Month Assessment
Trust Team Name Admit Disch
SSNAP
Level
CA AC
Combined
KI Level
D1 D2 D3 D4 D5 D6 D7 D8 D9 D10
PC KI Level
Number
Applicable
%
Applicable
Number
assessed
% Assessed
Scan SU Throm Spec Asst OT PT SALT MDT Std Disch Disch Proc
North of England - North West Coast SCN
Aintree University Hospitals NHS Foundation
Trust
University Hospital Aintree 152 147 C↓ A A C↓ C↓ E↓ D↓ B C↓ B C D↓ A A C↓ 105 98% 9 9%
Blackpool Teaching Hospitals NHS Foundation
Trust
Blackpool Victoria Hospital 153 159 E A↑ C↓↓ D↑ C D↑ D↑ D E E E E C A D↑ 93 91% 27 29%
Countess of Chester Hospital NHS Foundation
Trust
Countess of Chester Hospital 108 106 B A A B A↑ B C B↓ B B E↓ A↑ B A B 39 74% 25 64%
East Lancashire Hospitals NHS Trust Royal Blackburn Hospital 217 207 C A A C B↑ D C↑ D C D↓ C B A D↓ C 123 97% 27 22%
Lancashire Teaching Hospitals NHS
Foundation Trust
Royal Preston Hospital 174 182 C↑ A A C↑ C C↑↑ D D↑ A↑↑ B↑↑ C↑ C↑ B↓ D↓ C↑ 173 98% 3 2%
Mid Cheshire Hospitals NHS Foundation Trust Leighton Hospital 197 209 C A A↑ C A E E↓ B↑ A A C↓ A↑ B↑ A B 76 68% 68 89%
Royal Liverpool and Broadgreen University
Hospitals NHS Trust
Royal Liverpool University Hospital 179 171 B↑ B↓ A↑ B B D↑ B B A A D↑ A B↑ A B 146 95% 24 16%
Southport and Ormskirk Hospital NHS Trust Southport and Formby District General 149 138 C A A C B↓ E D B↑ A B E A↑ C↓ D C 78 99% 14 18%
St Helens and Knowsley Teaching Hospitals
NHS Trust
Whiston Hospital 298 276 A A A A A B B B↓ A↑ C C A B A A 171 74% 128 75%
University Hospitals of Morecambe Bay NHS
Foundation Trust
Furness General Hospital 67 62 C A↑ A C B↓ D↓ E C↓ B↓ C↑ E B↑ A↑ B C 55 100% 28 51%
University Hospitals of Morecambe Bay NHS
Foundation Trust
Royal Lancaster Infirmary 94 104 D A C↓ D A E E D E↓↓ C↑ E D A B D 90 100% 1 1%
Warrington and Halton Hospitals NHS
Foundation Trust
Warrington Hospital 92 89 D A↑ A D D↓ E C↑ E A B E B C A D 47 59% 30 64%
Wirral University Teaching Hospital NHS
Foundation Trust
Arrowe Park Hospital 193 191 A B↓ A A A C↓ B B A B C A A A A 93 80% 92 99%

44. Cheshire and Merseyside demographics
Population Prevalence of
CVD
Prevalence of
stroke
Prevalence
of AF
CHADS2>1
anticoagulated
Eastern Cheshire 194,793 10.4% 2.10% 2.1% 81.6%
Halton 125,722 9.7% 2.24% 1.7% 77.2%
Knowsley 145,903 10.4% 2.62% 1.5% 81.3%
Liverpool 465,656 9.8% 2.37% 1.5% 81.7%
South Cheshire 175,943 10% 2.07% 1.9% 79.9%
South Sefton 159,764 10.7% 2.52% 1.9% 80.9%
Southport and
Formby
114,205 11.7% 2.59% 2.2% 82%
St Helens 175,405 10.4% 2.33% 1.8% 81.3%
Vale Royal 102,144 9.5% 1.98% 1.7% 86.1%
Warrington 202,709 9.2% 1.86% 1.5% 80%
West Cheshire 227,382 10.1% 2.12% 1.9% 78.6%
Wirral 319,837 10.9% 2.53% 2.1% 81%
England 53,107,169 9.5% 2.07% 1.5% 81.3%
Data source: Cardiovascular intelligence network 2016

45. NOAC uptake across England by STP1
53.5% - 75%
49.4% - 53.5%
46.5% - 49.4%
44.6% - 46.5%
42.7% - 44.6%
40.2% - 42.7%
39.1% - 40.2%
37.8% - 39.1%
36.1% - 37.8%
34.4% - 36.1%
32.9% - 34.4%
31.6% - 32.9%
29.9% - 31.6%
27.4% - 29.9%
23.8% - 27.4%
16.2% - 23.8%
% of patients
% of patients who are prescribed a
NOAC for oral anticoagulation
1. NHS Business Services Authority. Medicines Optimisation Dashboard. June 2017. Available at:
https://apps.nhsbsa.nhs.uk/MOD/AtlasCCGMedsOp/MO%20CCG%20Dashboard%20(June%2017).xlsb. Accessed February 2018.
STP = Sustainability and Transformation Partnerships

46. Anticoagulation
Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban
or a vitamin K antagonist
1.5.2 Consider anticoagulation for men with a CHA2DS2-VASc score of 1.
Take the bleeding risk into account.
1.5.3 Offer anticoagulation to people with a CHA2DS2-VASc score of 2 or
above, taking bleeding risk into account.
1.5.4 Discuss the options for anticoagulation with the person and base the
choice on their clinical features and preferences.
NICE and anticoagulation1
1. NICE CG180. Available at http://guidance.nice.org.uk/cg180. Accessed March 2018.

47. ESC Guidelines – 2016 recommendations on AF
management1
Recommendations Class Level
Oral anticoagulation therapy to prevent thromboembolism is recommended for
all male AF patients with a CHA2DS2-VASc score of 2 or more
I A
Oral anticoagulation therapy to prevent thromboembolism is recommended in
all female AF patients with a CHA2DS2-VASc score of 3 or more
I A
Oral anticoagulation therapy to prevent thromboembolism should be
considered in all male AF patients with a CHA2DS2-VASc score of 1,
considering individual characteristics and patient preferences
IIa B
Oral anticoagulation therapy to prevent thromboembolism should be
considered in all female AF patients with a CHA2DS2-VASc score of 2,
considering individual characteristics and patient preferences
IIa B
Vitamin K antagonist therapy (INR 2.0-3.0 or higher) is recommended for stroke
prevention in AF patients with moderate-to-severe mitral stenosis or
mechanical heart valves
I B
When oral anticoagulation is initiated in a patient with AF who is eligible for a
NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is
recommended in preference to a Vitamin K antagonist
I A
1.. Kirchhof P et al. Eur Heart J 2016;37:2893-2962.

48. 16/17 National - Quality Outcome AF data1
1.NHS Digital. QOF Data 2016/17. Available at: http://digital.nhs.uk/media/33575/QOF-2016-17-Prevalence-achievements-and-exceptions-
at-regional-and-national-level/default/qof-1617-prev-ach-exc-reg-nat. Accessed March 2018.

49. Reduce clinical variation –
standardised pathways

50. The National Plan for Stroke in
England: 2018-2021

51. The National Stroke Plan
3 year
Plan
Ongoing
rehabilitation
& care
Urgent &
emergency
care
Prevention
Workforce
Leadership, data &
research

52. Preventing avoidable strokes –
primary and secondary prevention
• 9 out of 10 strokes associated with ten modifiable risk factors
• Population health approach (Making Every Contact Count, One You
campaign, Salt Reduction, Tobacco Control Plan, weight management
services, CQUIN’s for supporting alcohol reduction and smoking cessation)
• RightCare CVD Prevention programme, support from AHSN’s, PHE, NICE
and third sector to help CCG’s improve dectection and management
• ATRIAL FIBRILLATION – could prevent up to 14,220 strokes, saving £241
million over 3 years
• HIGH BLOOD PRESSURE – could prevent 14,500 strokes and 9,700 heart
attacks over 3 years
• PHE Act FAST campaign

53. • Full roll-out of RightCare CVD
Prevention Programme (more training
for pharmacists, self-management,
new technologies, wider range of
people trained to check AF / BP)
• Increase access to routine pulse
testing
• Include indicator on AF in CCG
Improvement & Assessment
Framework
• Roll out of RightCare CVD Prevention
Programme
• Include 140/90 BP target in CCG
Improvement & Assessment
Framework
• Increased uptake of Health Check
• Increase awareness of AF as risk factor
• Maintained investment in ActFAST
campaign
Prevention
Atrial
Fibrillation
• Reduce number of people
with undetected AF by 30%
• 85% of eligible AF patients
receiving anti-coagulation
• Improve warfarin TTR by x%
• 25% reduction in non
anticoagulated stroke
patients
High BP
• X% increase in hypertension
diagnosis
• 15% increase in % of adults
with controlled BP at 140/90
Awareness
• Continue to improve public
awareness of stroke
Activity
Ambition

54. • AF is one of the most important preventable risk factors for stroke disease
• Patients who suffer an AF associated stroke have poor outcomes
• Many patients with AF are still undetected and once diagnosed not receiving
the appropriate treatment with oral anticoagulation
• Tools exist to support delivery of appropriate care and treatment (detect,
perfect, protect)
• We all need to support primary and secondary care to deliver meaningful
change:
Clinical Change Champions
Education and sharing of evidence base
Awareness raising
Confidence building around oral anticoagulation
Summary points