Prescribers should consider new anticoagulants as an alternative to aspirin when treating patients with atrial fibrillation (AF), Nice has said.

Aspirin was less effective and less safe for patients with an increased risk of stroke than previously thought, Nice said to coincide with the publication of new AF guidance last week (June 18). It recommended a "new generation" of anticoagulants as the best treatment option.

In comparison to anticoagulants, which were under-prescribed in half of people with suspected or diagnosed AF,aspirin was more likely to cause bleeding, Nice said. It made a "strong recommendation" that aspirin should not be prescribed to patients with AF "solely on account of increased risk of stroke".

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	"Although the risks of anticoagulation increase with age, the evidence also shows that the benefits [of anticoagulants] outweigh the risks in the vast majority of people with AF," it said.

Unlike warfarin, an anticoagulant commonly used to treat AF, novel oral anticoagulants (NOACs) - such as apixaban, rivaroxaban and dabigatran - did not require regular monitoring, Nice said.

NOACs had been approved since 2012 and were "potential life savers" for warfarin-intolerant patients or those who found it difficult to control their blood clotting when taking the drug, Nice said. These newer anticoagulants should also be considered for newly diagnosed patients with an increased risk of stroke and for people taking aspirin for stroke prevention, it said.

Although warfarin was "cheap and effective", it had drawbacks including interactions with food and drink, Nice said. It also required patients to undergo regular monitoring and dose adjustments in special clinics, which impacted on patients' work and social life, it said.

As NOACs did not require monitoring, there were concerns that patients would fail to adhere to their treatment and Nice advised that pharmacists could "reinforce the importance" of the treatment each time they dispensed a prescription, in guidance on NOAC use published on the same day as the AF guidance.

Not all GPs could be expected to be "experts in anticoagulation", said Nice, which called for local anticoagulation "champions" to take the lead.

Nice recommended clinicians use a risk score calculator to assess the risk of stroke in AF patients and decide if they required anticoagulants.

Helen Williams, consultant pharmacist for cardiovascular disease at Southwark CCG, said pharmacists played a "vital" role in educating patients with AF about their medicines and the various treatment options.

Nice director of clinical practice Mark Baker said AF increased the risk of stroke "by up to five times" and caused around 12,500 strokes annually. The effective detection of AF and protection with anticoagulants could prevent around 7,000 strokes and 2,000 premature deaths each year, he added.

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