WPR talks to Manuel Reiberg, MD of Daiichi-Sankyo, about the impact of strokes on the population, particularly during the ongoing pandemic, and the necessity of effective detection and prevention strategies.

What have been the challenges put on healthcare systems with regards to protecting patients with a high risk of AF-related stroke during the COVID-19 pandemic?

The COVID-19 pandemic has forced all organisations to review the way they operate and assess how they can do things differently. Nowhere has this self-reflection been more necessary than in the delivery of preventative healthcare.

Specifically in stroke prevention, health systems have had to look across their populations to understand which patients can be supported and managed outside of hospital settings and in the community. Decision-makers have had to balance the need for patient safety while exploring how disruption to day-to-day services can be minimised through the adoption of novel ways of working.

What has this meant on a regional level in Wales specifically?

To limit the scope of the pandemic, which to date has sadly led to more than 1,500 deaths in Wales alonei, HCPs have risk-assessed patients with AF to ensure their treatment plans remain suitable. Practically this involved reviewing whether patients receiving warfarin could be switched to an appropriate DOAC, which avoids the need for regular blood tests for INR monitoring and thus the reliance on face-to-face interaction.ii

While this was essential to protect patients with detected AF, the challenge for all parts of the health system now needs to be on ensuring the safety of patients that remain undetected. Recent studies have highlighted the impact that lockdown policies have had on the detection of AF, which points to a potentially worrying downward trend across developed economies.iii

If we are to protect the significant number of patients in Wales living with this condition undetected, we must be open to collaboration, a partnership approach, and exploring the use of digital technology to optimise detection across the patient pathway.

With regards to stroke prevention in Wales, how important is collaborative working between healthcare professionals in improving population health?

Collaborative working across the healthcare system is incredibly important to improving population health outcomes, reducing health inequalities and protecting patients.

Stroke is the fourth biggest cause of death in Wales.iv It is estimated that AF causes 12,500 strokes in the UK every year and potentially 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection of patients at risk.v

There are significant cost-saving opportunities from better detection and management of AF, with some experts estimating a potential £4 billion worth of savings in societal costs by 2035.vi Locally, this is important, as the total cost of all-cause stroke in Wales is predicted to increase to £2.8 billion by 2035.iv,vi

In your view, what should be the longer-term goals in Wales for stroke detection and prevention?

We believe that all leaders across the system should work towards a common long-term goal of improved AF detection and management in the region. This is absolutely essential in order to keep patients out of hospital and reduce preventable CV events.

Around 76,000 people in Wales have been diagnosed with AF. It is estimated that there are thousands more living with undiagnosed AF across Wales.vii These patients are living with a serious undiagnosed condition that may greatly increase their risk of stroke.viii

Better detection and prevention can be done via a number of ways; including utilising available innovative technologies to support addressing the detection gap. For instance, the AF Audit Plus tool, developed by Public Health Wales, can help GPs look at lists of patients who are in the high-risk category for AF or who have already been diagnosed. It can also be achieved through embedding a dedicated patient-centric, clinical pathway for AF across all Health Boards, as has been proposed by the Wales Cardiac Network.ix

Long-term targets, as we have seen with the NHS Long Term Plan in England, enable the creation of shared and focussed objectives for all partners across the system to pursue. The Stroke Delivery Plan published in 2017, which included objectives to improve the detection and management of AF, offers the foundations which can be developed further.x

As a committed partner, we wish to support the NHS in Wales to seize the opportunities presented by better prevention of AF-related stroke, both at a customer-level in terms of cost-savings but most importantly at a patient-level in terms of health outcomes.

What are the ambitions of Daiichi-Sankyo going forward with regards to stroke prevention in Wales?

As an organisation we hold a lasting commitment to supporting healthcare professionals to deliver effective preventative health interventions that improve the lives of patients.

We support the calls for a dedicated AF strategy for Wales which will drive forward service improvement in detection and management, and includes clear long-term targets for the wider system to work towards.

I passionately believe, now more than ever, that the role of pharmaceutical companies is changing. The pandemic response has demonstrated that industry and healthcare provider collaborations can achieve transformations in the standard of care.

References

i. BBC, 2020. Coronavirus cases in Wales. Available: https://www.bbc.co.uk/news/uk-wales-51888681

ii. Williams, 2020. Guidance for the safe switching of warfarin to DOACs. Available: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Coronavirus/FINAL%20Guidance%20on%20safe%20switching%20of%20warfarin%20to%20DOAC%20COVID-19%20Mar%202020.pdf?ver=2020-03-26-180945-627

iii. Holy, A et al, New-onset Atrial Fibrillation: Incidence, Characteristics, and Related Events Following a National COVID-19 Lockdown of 5.6 Million People, Eur Heart J., 24 June 2020

iv. Stroke Association. State of the nation report 2018. Available: https://www.stroke.org.uk/sites/default/files/state_of_the_nation_2018.pdf

v. NICE, 2014. Thousands of strokes and deaths preventable from ‘silent killer. Available: https://www.nice.org.uk/news/article/thousands-of-strokes-and-deaths-preventable-from-silent-killer

vi. Stroke Association. Current, future and avoidable costs of stroke in the UK. Available: https://www.stroke.org.uk/sites/default/files/costs_of_stroke_in_the_uk_report_-executive_summary_part_2.pdf

vii. British Heart Foundation, 2020. Wales Factsheet. Available: https://www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics-wales-factsheet.pdf?la=en

viii. Chest, Heart and Stroke. Atrial Fibrillation. Available: https://nichs.org.uk/information/risk-factors/atrial-fibrillation?

ix. Wales Cardiac Network. All Wales Clinical Pathways – Atrial Fibrillation. Available: http://www.wcn.wales.nhs.uk/all-wales-clinical-pathways

x. NHS Wales, 2017. Stroke delivery Plan. Available: https://gov.wales/sites/default/files/publications/2018-12/stroke-delivery-plan-2017-to-2020.pdf