Atrial Fibrillation Advisor

Atrial Fibrillation Advisor templates

AFA001 – AF Advisor core template

The core template is a comprehensive guide designed to help you assess and inform patients with atrial fibrillation about the risks and benefits of anticoagulation.

The template contains one page broken down into 12 different sections; each section and its components contain visibility rules. This means that when you run the template in a consultation, you’ll only see data and information relevant to the selected patient.

Each section is described in detail below.

Provides general guidance on the use and purpose of the template.

The data quality section displays the latest coded values of the data used to generate the stroke risk score, bleeding risk score and treatment choices.

You should use clinical judgement when assessing risk score and treatment choices; check that the latest values used to calculate the score are accurate before analysing the risk score or treatment choices. For example, if the latest value of a clinical code has not been recorded for a considerable amount of time e.g. over six months ago, the value may have changed since it was last recorded.

Click  to view more details about a coded entry in the Detailed View pane.


Data quality section in the AFA001 – AF Advisor core template

Alerts are displayed here if one or more of the following is true:

  • A patient is currently taking more than one anticoagulant.
  • A patient is currently on a DOAC dosage that is not compatible with their estimated creatinine clearance calculation.
  • A patient is currently taking an antiplatelet.

    (It may not be appropriate to prescribe both an anticoagulant and an antiplatelet, as stopping the antiplatelet may reduce bleeding risk in itself.)

  • A patient was previously taking an anticoagulant where this was stopped e.g. if an adverse reaction to anticoagulants was recorded.


Major alerts section in the AFA001 – AF Advisor core template

A patient’s CHA2DS2-VASc score is automatically calculated when you run the template. The warning message shown under the Stroke Risk header varies depending on the score result:

Score Warning Message
0 Anticoagulation not advised.
1 Anticoagulation not advised if the patient is female, should be considered if the patient is male.
2 – 4 Anticoagulation should be considered.
5 – 9 Anticoagulation should be offered (stroke risk is high).

The breakdown of a patient’s stroke risk is displayed beneath the CHA2DS2-VASc score and warning message. Points are allocated if a patient meets any of the following criteria:

  • Hypertension (1 point)
  • Diabetes Mellitus (1 point)
  •  Age
    • 65-74 years old (1 point)
    • 75 or over (2 points)
  • Congestive heart failure (1 point)
  • Prior stroke, TIA (transient ischemic attack) or thromboembolism (2 points)
  • Vascular disease (1 point)
  • Gender (1 point if patient is female)


Stroke risk calculator including a breakdown of the CHA2DS2-VASc score

The CHA2DS2-VASc score is generated using the concept driven CHA2DS2-VASc® calculator, which is a certified medical device in EMIS Web.

To interpret a patient’s stroke risk over the next 1 year based on their CHA2DS2-VASc score, the template contains a hyperlink to the NICE Patient Decision Aid.

Additionally, you can calculate an estimate of an individuals risk of stroke over the next 10 years using the QStroke calculator embedded into the template.

A patient’s HAS-BLED score is automatically calculated when you run the template. The warning message shown under the bleeding risk header will vary depending on the score result.

Score Warning Message
0 – 2 Bleeding risk is likely to be low.
3 – 4 15 out of 1000 patients taking an anticoagulant for a year with a risk score of 3 will have major bleeding. This increases to 21 out of 1000 with a risk score of 4. Assess the risks and benefits before anticoagulation.
5 – 9 Increased risk of major bleeding. Assess the risks and benefits before anticoagulation.

The breakdown of a patient’s bleeding risk is displayed beneath the HAS-BLED score and warning message. 1 point is assigned for each of the following conditions that a patient has:

  • Uncontrolled blood pressure (systolic BP > 160)
  • Abnormal renal function (Dialysis, transplant or creatinine > 200)
  • Abnormal liver function (Cirrhosis, bilirubin and ALT raised)
  • Stroke
  • Possible bleeding predisposition

    (Clinical judgement is required to decide whether the last recorded date of anaemia indicates active bleeding or not. Score this as 0 if you don’t judge the current anemia to be indicative of active bleeding, otherwise this is automatically scored as 1.)

  • Labile INR (time in therapeutic range < 60%)
  • Age > 65
  • Medication (prescribed NSAIDs or Antiplatelets)
  • Alcohol (8 or more units a week)


Bleed risk calculator including a breakdown of the HAS-BLED score

If a possible bleeding predisposition is present (i.e. current anaemia, previous anaemia, previous marked anaemia) a score range is displayed rather than a fixed score. The calculator cannot resolve the score to a single value because clinical judgement is required to decide if the possible bleeding predisposition should contribute to the score.

Instructions for calculating bleeding risk are shown in the Information about Bleeding Risk section


HAS-BLED score range shown where a possible bleeding predisposition is found

The HAS-BLED score is generated using the concept driven HAS-BLED® calculator, which is a certified medical device in EMIS Web.

To assist you in interpreting a patient’s bleeding risk based on their HAS-BLED score, the template contains a hyperlink to the NICE Patient Decision Aid.

The following advisory information is displayed in this template section:

Reference range for abnormal liver function

HAS-BLED defines abnormal liver function as: A bilirubin value greater then two times the normal value in association with ALT values greater than three times the normal value. The AF Advisor toolkit equates this to an ALT of 120 umol/L and bilirubin of 42 umol/L. Use clinical judgement if your reference ranges differ.

Bleeding Predisposition – Clinical Judgement required

Score 1 for possible bleeding predisposition if:

  • There is current anaemia that you consider indicative of active bleeding (i.e. of recent onset or declining haemoglobin) or,
  • there is a previous marked anaemia (Hb<115g/L males, <95g/L females) or,
  • there is a past history of a significant bleeding episode i.e. requiring hospital admission or transfusion.

The patient’s latest Haemoglobin and Last Recording Bleeding episodes (if applicable) are also displayed in this section.

Note on bleeding risk calculations (time in therapeutic range (TTR))

  • Patients on warfarin should have their TTR recorded and used as part of the HAS-BLED bleeding risk calculation.

    You have manually entered a TTR reading. NICE advise that you calculate TTR at each visit. When calculating TTR, NICE advise use of a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing. Exclude measurements taken during the first 6 weeks of treatment. Calculate TTR over a maintenance period of at least 6 months.

  • Patients on warfarin should have their TTR recorded and used as part of the HAS-BLED bleeding risk calculation.

    There is no manually entered TTR. The TTR has been calculated from the INR readings present in the patient record. The TTR reading is updated at each visit. The calculation uses the proportion of tests in range method. An externally entered TTR calculation using the Rosendal method is preferred. The current calculation has been made over the last 6 or 12 month period depending on the length of treatment/monitoring recorded. TTR is not calculated if there is less than 6 months of data. The calculation excludes readings from the first 6 weeks of treatment

  • Patients on warfarin should have their TTR recorded and used as part of the HAS BLED bleeding risk calculation.

    There is no manually entered TTR reading and there is inadequate data to calculate a TTR reading from the patient record. The reported HAS-BLED bleeding risk may be underestimated if this patients INR is unstable.

    NICE advise that patients on warfarin should have:

    a. TTR assessed at each visit
    b. TTR calculations over at least 6 months
    c. INR monitoring intervals of up to 12 weeks
    d. The first 6 weeks of readings excluded from the TTR calculation.

    To comply with NICE guidance the AF Advisor TTR calculator requires at least 3 INR readings in 6 months or 4 in a 12 month period. Warfarin treatment and INR readings must have spanned at least the last 58 weeks (to allow for the exclusion of readings taken in the first 6 weeks of treatment).

Reducing bleeding risk

To reduce bleed risk, correct any modifiable risk factors shown. For example, if a patient’s alcohol consumption is over eight units per week, you can advise the patient they need to reduce their alcohol intake.

Modifable risk factors are marked as **Modifiable Risk** in the breakdown of the patient’s HAS-BLED score displayed in the previous template section.


Modifable risks highlighted in the HAS-BLED score details section

The AF Advisor template will check the patient record for the following contraindications to anticoagulation:

  • User entered contraindication code present
  • Malignancy
  • Bleeding disorder
  • Thrombocytopenia
  • Bleeding episode
  • Vascluar aneurysm
  • Oesophageal varices
  • Intracranial bleed
  • Hepatic impairment
  • Renal test > 12 months old
  • Estimated creatinine clearance <15
  • Adverse reaction to DOAC
  • Current prescription for Ketoconazole active
  • Recent surgery
  • Female of child bearing age

Details of any contraindications the selected patient has and when they were last recorded are displayed under the contraindications alert.


Contraindications section including information about each contraindication found on  a patient

This section displays considerations that should be taken into account before prescribing an anticoagulant.

There is a hyperlink to the NICE Patient Decision Aid which contains a summary of the risks and benefits of prescribing warfarin or a Direct Oral Anticogulant (DOAC).

Additional alerts are displayed here if:

  • The patient is already on an anticoagulant.
  • The patient is already on an anticoagulant but the current dose prescribed is not consistent with the suggested dosing options.

This section displays information about anticoagulant treatment options (drug and dose). The treatment options shown are calculated from the information coded in the patient record. The calculation takes account of the latest recorded weight, and serum creatinine, the patient’s age, and coexistent P-glycoprotein medication use. Dosing options are returned based on the prescribing criteria for each medication as defined in the medication’s summary of product characteristics data sheet.

The treatment choices information displayed supports the clinician in making prescribing decisions. It does not replace clinical acumen and the clinician remains solely responsible for their prescribing choices.

The appropriate dose of anticoagulation may vary from that shown where there is a dual indication for anticoagulation.

  • Warfarin
  • Rivaroxaban
  • Apixaban
  • Didigatran
  • Edoxaban


Treatment choices section with examples of suggested doses shown.

Select whether you want to use AF Advisor assisted prescribing upon saving the template by ticking the Tick here to generate a new prescription using assisted prescribing checkbox.

If this option is ticked, the AFA003 data entry protocol will launch once you complete the template. The protocol will ask you to select the anticoagulant treatment option of your choice from those listed in the template. A prescription is then automatically generated.


Assisted prescribing section

NICE guidelines recommend that adults with atrial fibrillation who are prescribed anticoagulation discuss the options with their healthcare professional at least once a year.

Use this section of the template to document the following:

  • The patient has commenced Direct Oral Anticoagulant Therapy.
  • An atrial fibrillation annual review.
  • The patient is unsuitable or has dissented from anticoagulant treatment.

The template version, clinical contributors, technical contributors and references are displayed here.

CHA2DS2-VASc calculator template

The CHA2D2S-VASc calculator template is embedded into the AFA001 – AF Advisor core template and found in the Stroke risk calculator section. It uses the CHA2DS2-VASc score to calculate the risk of a patient with atrial fibrillation suffering a stroke. You can use this information to assess your at risk patients.

The CHA2DS2-VASc score is generated using the concept driven CHA2DS2-VASc® calculator, which is a certified medical device in EMIS Web.

HAS-BLED calculator template

The HAS-BLED calculator template is embedded into the AFA001 – AF Advisor core template and found in the Bleeding risk calculator section. It uses the HAS-BLED score to calculate the risk of bleeding in people who are starting or have started anticoagulation. The higher the score, the higher the risk.

The HAS-BLED score is generated using the concept driven HAS-BLED® calculator, which is a certified medical device in EMIS Web.

Atrial Fibrillation Advisor protocols

AFA002 – Alert protocol

The alert protocol generates a pop-up alert on patients who are diagnosed with atrial fibrillation. There are two different alert messages that can display, depending on a patient’s circumstances:

This is a high priority alert, which indicates immediate action may be required. The high priority alert appears in the Care Record if:

  • The patient is currently on more than one anticoagulant.
  • The patient has a high stroke risk (CHA2DS2-VASc score of 5 – 9) and has not been prescribed an anticoagulant.
  • The patient has a low stroke risk (CHA2DS2-VASc score of 0 – 2) and is currently prescribed an anticoagulant.
  • The patient is currently prescribed an anticoagulant dose that is not consistent with the AF Advisor suggested dose.

Double-click the alert to open the AFA001 – AF Advisor core template and review the prescribing options.


High priority anticoagulation alert highlighted

This is an information alert, and indicates no immediate action needs to be taken. Double-click the alert to view more information; this opens the AFA001 – AF Advisor core template.


Medium priority anticoagulation alert highlighted

The alert tooltip text displays information about their current anticoagulation status, latest risk scores and whether any action needs taking.

Hover your cursor over an alert to display tooltip text.

View the image and key below to understand the information shown in the tooltip text:

  1. A live CHA2DS2-VASc score (based on the latest recorded data available).
  2. A live HAS-BLED score (based on the latest recorded data available).
  3. What drug(s) the patient is currently anticoagulated with, if applicable.
  4. The patient’s latest estimated creatinine clearance score, based on the most recently recorded weight and creatinine levels.
  5. If the patient has been exception reported for anticoagulation, this is shown (including the date that this was recorded on).
  6. If any contraindications have been recorded a message is displayed to advise this.
  7. Any modifable bleeding risk factors, if applicable these are listed.
  8. Warnings (marked with !) will appear if:
    • The patient is currently being prescribed more than one anticoagulant.
    • The patient is currently on an anticoagulant dose that doesn’t match the dose recommended by the AF Advisor template based on the current data in the patient record.
    • The stroke risk score is low and the patient is anticoagulated.
    • The stroke risk score is high and the patient is not anticoagulated.

Tooltip text displayed based on the selected patient data

To view more information, double-click the alert to open the AFA001 – AF Advisor core template.

AFA003 – Protocol to add data to record

The AFA003 protocol is designed to work in conjunction with the AFA001 – AF Advisor core template. It has two functions:

  1. It allows you to quickly and easily record the calculated estimated creatinine clearance, CHA2DS2-VASc score and HAS-BLED score.
  2. It runs the assisted prescribing system that allows you to quickly and easily prescribe the anticoagulant option of your choice from the list of treatment options displayed in the template.
Drug Dose
Apixaban 2.5mg twice a day
5mg twice a day
Dabigatran 110mg twice a day
150mg twice a day
Edoxaban 30mg once a day
60mg once a day
Rivaroxaban 15mg once a day
20mg once a day

Follow the instructions below to use the AFA003 data entry protocol to assist with prescribing an anticoagulant:

  1. Run the AFA001 – AF Advisor core template.
  2. In the Assisted Prescribing section, tick the option that says Tick here to generate a new prescription using assisted prescribing.
  3. Complete the template and save the consultation to launch the protocol.
    The protocol codes the patient’s current CHA2DS2-VASc score, HAS-BLED score and estimated creatinine clearance in the background.
  4. Click OK once you’ve read the message that appears stating you are solely responsible for ensuring the prescribing option shown:

    Text advising the prescriber is responsible for issuing any of the suggested dosesA Multiple Choice Question is displayed.
  5. Either select the anticoagulant you wish to issue, or select I do not wish to prescribe to close the protocol.

    Anticoagulant prescribing options to choose fromThe Issue screen is displayed.
  6. Selecting a treatment option populates the Issue screen with prescription details for the drug and the dosage displayed in the template treatment options section. Complete the issue to prescribe the drug and dosage displayed.

    Issue screen after Apixaban has been selected for a patient from the protocol

By default, the prescription is generated as a repeat prescription authorised for 6 issues with each issue providing 28 days’ supply. Following issue, you can amend the prescription type, authorisation period and supply duration in the medication screen if required.

If none of the dose options for the selected drug match the patient’s suggested doses, the Add a Drug screen is not populated and a message is displayed advising the drug is not compatible. Click OK to return to the anticoagulant choice screen.
Warning message stating that the selected drug is not compatible

AFA004 – Drug issue prescribing warning

This additional alert protocol is designed to produce a clear and obvious warning message if a patient is currently on more than one course of an anticoagulant.

The alert advises that a prescriber should remove the unwanted anticoagulant and is displayed when a patient record is loaded or a drug is issued.


Anticoagulants alert protocol warning message

Atrial Fibrillation Advisor searches

The AF Advisor searches identify your patients with Atrial Fibrillation who are currently on a dose of anticoagulant that varies from the dose calculated by the AF Advisor core template.

You can run these searches and view the information displayed in the corresponding list reports to investigate and correct any dosing errors.


Atrial Fibrillation Advisor review dose searches

Licensed use

Use of AF Advisor will be considered licensed provided the following criteria are met:

  • Users must agree to take full responsibility for their prescribing choices and treatment decisions.
  • Users must have read the user guide in full before use and agree to follow the guidance within.
  • Users will only use AF Advisor when the clinical record is contemporaneous and complete. Users are responsible for ensuring the clinical record is both contemporaneous and complete and should take careful account of the guidance on data quality when considering whether the health record is fit for use.
  • Users agree to read and take into account the full information provided by the alert, template and protocol before making clinical decisions.
  • Users agree to use clinical judgement to consider information that may not be recorded in a patient record that may impact treatment e.g. lifestyle choices.