Atrial Fibrillation


‘It is estimated that 1.36 million people are living with atrial fibrillation (AF). AF is a heart condition and is the most common form of cardiac arrhythmia. It is associated with increased risk of stroke as well as reduced cardiac performance and early mortality. Stroke patients with uncontrolled AF are more likely to be diagnosed with severe stroke which can lead to poorer outcomes. AF is often asymptomatic and frequently unrecognised. Estimated prevalence is around 2.4% ‘. Public Health England, March 2015.

Atrial Fibrillation Programme Projects

Aim: To reduce AF related stroke and associated mortality and morbidity

  • Raising the profile of AF with primary care practitioners within the region
  • Raising the profile of latest AF guidance, CG180, and patients to be treated according to NICE
  • Greater detection of those with undiagnosed AF in primary care
  • Understand and implement tools to ensure patients with AF are treated and audited
  • Improve treatment of those on AF Registers in primary care

The pathway below shows the AF Pathway in terms of detection through to perfecting treatment.

Detect: AF by a pulse check
Protect: from AF-stroke by using anticoagulation (not aspirin)
Correct: the irregular rhythm with access to the appropriate treatment
Perfect: the patient care pathway

The itemised list below corresponds to the AHSN-NENC suite of resources.

Detect Protect Correct Perfect
AliveCor INR Newcastle Project Expert Resource AF Card Deck
Diabetes Podiatry CCG Education via Primary Care Cardiovascular Society AF Review in S. Tees & N. Yorkshire
E-learning resource
Other work:
  • Infographics Tool – QOF and SSNAP data via Clinical Networks for CCG engagement.
  • Sustainability Work Proposal – not worked up yet, but with industry.
  • JWA collaboration with industry – in progress and embargoed at present.

The following resources provide an overview of the programme:

The Atrial Fibrillation Programme is joint work between the AHSN and the Northern England Cardiovascular Network. The aim of the programme is to:

Reduce the number of strokes as a result of undiagnosed and untreated AF through targeted case finding and optimal treatment of patients already identified with AF through anticoagulant use.

The current estimates suggest that 474,000 people are living with undiagnosed AF across England. Furthermore, a number of recent UK studies suggest that, among patients in whom AF has been detected, best practice of discussion and adoption of appropriate treatment is quite low overall and subject to marked variation in different areas.

Blood Clot Risk

QOF suggests only 65% of people with AF are on AF registers in primary care. Undiagnosed prevalence for CCGs in the North East and North Cumbria vary between 0.6% and 1.0% which equates to 25,619 patients (NCIN, Public Health, England).

Priority areas will focus on:

  • Raising the profile of AF with primary care practitioners within the region.
  • Raising the profile of latest AF guidance, CG180, and patients to be treated according to NICE.
  • Offer patients information about AF, treatment options including risks and benefits.
  • Greater detection of those with undiagnosed AF in primary care.
  • Understand and implement tools to ensure patients with AF are treated and audited.
  • Improve treatment of those on AF Registers in primary care.


The Atrial Fibrillation Programme started on 13 April 2015 and at present 9 projects have been agreed. They are:

  1. CCG engagement: offering support and resources to CCGs and individual practices with a suite of options.
  2. AF Card Deck: a resource aimed at primary care including top tips for diagnosing stroke and risk assessment, checklist for GPs, helping a patient to choose an aniticoagulant and warfarin vs NOAC information sheet. This project has now been completed and the card deck has been distributed to almost 2,200 GPs across the North East and North Cumbria. An electronic version of the card deck is now available to download.
  3. Local education event: aimed at increasing awareness, discussing anticoagulant choices, examining NICE guidance, discovering the benefits of treating and detecting patients, resources available to help.
  4. Promotion of opportunistic pulse checking at flu clinics and LTC/ health checks by providing the hand-held device AliveCor for interested practices: work with areas who wish to find patients with undiagnosed AF through various methods and support including podiatry teams who can detect an irregular pulse when patients with diabetes have their annual footcheck.
  5. Promotion of shared decision-making about AF: help clinicians to understand how to undertake SDM, promote decision-making aids and to disseminate the benefits of shared decision-making.  A training event was held in June and was aimed at Primary Care with the support of the Stroke Association.
  6. INR and self-monitoring of warfarin: promote roll out potential of work already done and examine Telehealth options through the Telehealth Programme.
  7. Work with GP Federations to improve treatment of those on AF Registers in primary care: some Federations are already working on this and moving forward in building their AF registers.
  8. AF Patient Review: with the support of South Tees Arrhythmia Service and industry the South Tees Arrhythmia service have been able to review patients on practice AF Registers in South Tees and Hambleton and Richmondshire to ensure patients are receiving optimal treatment.
  9. Educational webinar: based upon the AF Card Deck we will have an education resource that NHS staff will be able to access at any time through the AHSN website.

We will be working with other AHSN Programmes such as telehealth and medicines optimisation so that maximum impact and momentum can be achieved. The North East Quality Observatory System will support implementation and measurement for improvement. We are engaging with other organisations such as the third sector and pharmaceutical companies to help us move forward.

How can you help? Anyone who is interested, either as recipient of resources or as someone who would like to get involved more formally, please get in touch with the AF Programme Manager Kate Mackay on

The impact that the programme will have on the healthcare system and patients –

  • There are an estimated 25,619 patients with undiagnosed AF in this AHSN area and each stroke prevented could save £23,315 (NAO, 2010).
  • Without treatment 1 in 20 patients will have a stroke which means we could prevent strokes in 1281 patients and consequently save £29.86M.

To find out more about the Atrial Fibrillation Programme please contact the Programme Lead, Kate Mackay:


  • Starting Anticoagulation with Jack – (PROTECT and PERFECT) – this video has been developed by Wessex AHSN to provide advice for patients, their family and carers after anticoagulants have been prescribed. It explains about clotting and why abnormal clots can form as people age. The different types of medicines are shown, and Jack and his son talk about Jack’s concerns, side effects and sources of support. There is also a Patient Information Leaflet developed by Wessex AHSN to accompany this video.