Atrial fibrillation: diagnosis and management

Resource impact summary report

The NICE guideline on atrial fibrillation: diagnosis and management published in April 2021. It includes guidance on providing the best care and treatment for people with atrial fibrillation, including assessing and managing risks of stroke and bleeding.

The guideline recommendations have been reviewed for their potential impact on the NHS workforce and resources.

Implementing the guidance is expected to lead to a resource impact as a result of the following recommendations:

• Offer anticoagulation with a direct-acting oral anticoagulant to people with atrial fibrillation and a CHA₂DS₂-VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (recommendation 1.6.3).
• Consider anticoagulation with a direct-acting oral anticoagulant for men with atrial fibrillation and a CHA₂DS₂-VASc score of 1, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance (recommendation 1.6.4).
• If direct-acting oral anticoagulants are contraindicated, not tolerated or not suitable in people with atrial fibrillation, offer a vitamin K antagonist (recommendation 1.6.5).

Since publishing these recommendations, NHS England and NHS Improvement have published an operational note, which outlines the results of the national procurement exercise for direct-acting oral anticoagulants (DOACs) and the resulting commissioning recommendations. The NICE guideline and this summary report should be read in conjunction with the operational note.

It is anticipated that the proportion of people with atrial fibrillation treated with warfarin will decrease. It is assumed that this reduction in warfarin use will correspond to an increase in the use of the 4 DOACs currently approved for use by NICE.

Moving away from warfarin to DOACs may lead to a reduction in the need for anticoagulation clinics.

The expected move away from warfarin to DOACs for stroke prevention in atrial fibrillation reflects changes already happening at the time the guideline published. This would have continued without the guideline update. The change in practice may have been accelerated during the COVID-19 pandemic because people taking DOACs do not need to attend regular monitoring appointments.

The costs for anticoagulant treatments mainly fall within primary care because this is where most prescribing for atrial fibrillation takes place.

A resource impact template is available for local modelling and should take into account prices in the framework agreement for DOACs announced by NHS England that went live on 1 January 2022. The template can also be amended to take into account any local population growth estimates.

Atrial fibrillation services are commissioned by integrated care systems, clinical commissioning groups and NHS England. NHS England commission adult specialist cardiac services including complex cardiac rhythm management, complex interventional cardiology services and high-cost devices for ablation. Providers are primary care GP services, community services and NHS hospital trusts.