Table 5.

Best-practice strategies for implementation of the ESC 2012 guidelines and rationale for such strategies

Strategy	Rationale
Practical
Develop hospital and department protocols and checklists based on national/local guidelines and implement quality indicators	Provides clinical practical guidance for day-to-day management of patients with AF and allows measurement of guideline adherence
Regular multidisciplinary team meetings and local quality audits	Allows assessment of individual patients and can act as an internal check to ensure they are being managed in line with guideline recommendations Enhances peer-to-peer learning experience
Plan follow-up visits and laboratory check-ups	Ensures patients are compliant with guideline-recommended therapy and reduces the risk of complications
Provide clear practical guidance on the use of NOACs	Provides reassurance for physicians not experienced in the use of these drugs
Implement CHA2DS2-VASc and bleeding risk checklists before prescribing NOACs and at every follow-up visit	Ensures identification of patients suitable for antithrombotic therapy and those at increased risk of bleeding
Implement compliance checks, e.g. specific questions, pill ‘counting’, diary completion, SMS messages or alarm calls to take tablets	Ensures patients are compliant with guideline-recommended therapy, improves adherence and reduces the risk of complications
Educational
Regularly disseminate ESC/national and local guideline information and updates	Raises awareness of guidelines
Develop timely country-specific/local guidelines based on the ESC recommendations	Allows recognition of country-specific requirements, such as access, so that guidelines are compatible with local conditions
Re-train/educate nurses currently involved in anticoagulation/warfarin clinics to take on a more general role in initiation and management of NOACs	Can provide an established point of contact through which patients can receive advice on anticoagulation with the NOACs
Develop simple algorithms for specific populations of patients with AF, as per Figure 2 (e.g. post-ischaemic stroke, post-haemorrhagic stroke, geriatric patients)	Provides guidance on when and how to start NOACs and for how long in these patients
Inform physicians on how to educate patients on the importance of adherence to therapy	Limits the likelihood of non-adherence to guideline-recommended protocols
Access
Approach the responsible person within your healthcare system to: Highlight to key target groups (e.g. budget holders, policy makers, formulary gate keepers, the media, patient groups) the potential impact of not providing access to guideline-recommended therapies, from both financial and clinical perspectives	Raises awareness that AF is a significant risk factor for stroke and that AF-related stroke is preventable
Perform country-specific cost-effectiveness analyses of the NOACs Educate payers/budget holders about better utilization of anticoagulants, including NOACs, highlighting potential long-term cost benefits	Provides payers/budget holders with more robust evidence to consider the use of the NOACs as first-line therapy –
Inform politicians, patient groups and the media about differences in access to AF stroke prevention treatment within regions or countries Lobby parliamentary and healthcare bodies for equality of access to guideline-recommended therapies globally or across regions	Puts pressure on policy makers to provide equality of care for stroke prevention in patients with AF with regards to medication

AF, atrial fibrillation; CHA₂DS₂-VASc, Congestive heart failure/left ventricular dysfunction, Hypertension, Age ≥75 years (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65–74 years, Sex category (female); NOAC, non-vitamin K antagonist oral anticoagulant; SMS, short message service; ESC, European Society of Cardiology.