Atrial fibrillation (AF) - QOF indicator

Atrial fibrillation indicators

The atrial fibrillation (AF) indicators in QOF 2026/27 cover stroke risk assessment and anticoagulant prescribing for patients at increased risk. A notable feature is the emphasis on direct-acting oral anticoagulants (DOACs), while allowing a Vitamin K antagonist to count towards achievement when a DOAC is declined or clinically unsuitable. The guidance also links this work to the newly published 10 year health plan and its cardiovascular mortality ambitions.

Ongoing management

Why AF is included in QOF

Around 2% of adults have AF, making it the most prevalent heart rhythm disorder, and estimates indicate that it is becoming more common. Palpitations and breathlessness are frequent presentations, although an absence of symptoms can mean that AF remains undiagnosed.

Without treatment, AF substantially raises stroke risk. Approximately 20-30% of all strokes are thought to be attributable to AF, which is also linked to greater mortality and considerable morbidity. It occurs more often in men than women, and prevalence rises with age and alongside heart disease, diabetes, obesity and hypertension.

AF006: stroke risk assessment

AF006 is based on NICE IND127.

Rationale

NICE recommends using CHA2DS2-VASc to assess stroke risk in people with paroxysmal, persistent or permanent AF, whether or not they have symptoms. This recommendation also applies to atrial flutter and to people who remain at risk of recurrent arrhythmia after cardioversion has restored sinus rhythm.

CHA2DS2-VASc incorporates congestive heart failure, hypertension, age, diabetes, stroke, vascular disease and sex. The total can reach nine points. Most components attract one point; the higher weighting for previous stroke or transient ischaemic attack (TIA), and for age ≥75, is represented by the ‘2’ in the score:

• C: one point for congestive heart failure.

• H: one point for hypertension.

• A2: two points for age 75 or over.

• D: one point for diabetes mellitus.

• S2: two points for a history of stroke, TIA or thromboembolism.

• V: one point for vascular disease, such as peripheral arterial disease (PAD), myocardial infarction (MI) or aortic plaque.

• A: one point for age 65-74 years.

• Sc: one point for female sex.

Reporting and verification

The AF006 definition in the table sets out the qualifying requirements. Reassess stroke risk annually, except where a score of 2 or more has already been recorded using either:

• CHA2DS2-VASc at any time; or

• CHADS2 before 1 April 2015. This score incorporates congestive heart failure, hypertension, age 75 or over, diabetes and stroke.

AF008: anticoagulant prescribing

AF008 is based on NICE IND247.

Rationale

The newly published 10 year health plan includes a commitment to develop a modern service framework for cardiovascular disease. Its target is a 25% reduction in premature deaths from heart disease and stroke over the next decade.

AF008 supports offering anticoagulant treatment to people with AF whose stroke risk is raised. Compared with the general population, people with AF have a fivefold stroke risk, and this arrhythmia accounts for 20–30% of all strokes. The Stroke Association estimates that adequate AF treatment could prevent around 7,000 strokes and save over 2,000 lives each year in England alone.

The indicator was introduced to help deliver the NHS Long Term Plan's ambition to reduce strokes and also contributes to the aim of reducing premature deaths from heart disease and stroke. Its objectives are to:

• Raise the proportion of patients with AF at risk of stroke who receive an anticoagulant prescription.

• Increase the share of anticoagulant prescribing accounted for by DOACs.

Around two thirds of AF-related strokes can be prevented with anticoagulation. Nevertheless, approximately 9% of patients with AF who are at risk of stroke receive no anticoagulant treatment.

NICE guideline NG196 on AF diagnosis and management places DOACs ahead of warfarin as first-line treatment. Serious bleeding, especially intracranial haemorrhage, is a greater risk with warfarin. The lower monitoring burden of DOACs can release primary care capacity and improve patients' quality of life. Further advantages over warfarin include:

• Predictable pharmacokinetic and pharmacodynamic behaviour, allowing fixed doses.

• Few interactions with medicines or food, without dietary restrictions.

• A short half-life, with effects that start and wear off rapidly.

• Consistent effects on coagulation, removing the need for routine clotting-factor monitoring.

• A broad therapeutic window.

Practices can meet AF008 by prescribing a DOAC to patients with newly diagnosed AF or by switching those taking warfarin, in keeping with NG196. Any switch must be clinically appropriate and follow a shared decision-making discussion.

The indicator allows for patients who cannot appropriately switch to a DOAC or who choose not to after discussing it with their clinician. Continuing warfarin in either circumstance counts towards achievement rather than disadvantaging the practice. The indicator definition above and the business rules provide further detail.

Reporting and verification

Use the AF008 definition in the table to establish the qualifying requirements.