Log in to MyACC
Stroke Risk Reduction in AF Through Pharmacist Prescribing
Quick Takes
- Patients with AF were more likely to receive optimal oral anticoagulation (OAC) therapy when prescribed by a pharmacist compared to referral to a physician.
- Community-based pharmacists can potentially reduce the risk of stroke for patients with AF by ensuring optimal OAC therapy is prescribed.
Study Questions:
Does pharmacist-led oral anticoagulation (OAC) prescribing increase the delivery of stroke risk reduction therapy in patients with atrial fibrillation (AF)?
Methods:
Patients aged ≥65 years with at least one additional stroke risk factor and known, untreated AF (no OAC prescription or suboptimal OAC dosing) or previously unrecognized AF were randomized to either early or delayed pharmacist intervention. Previously unrecognized AF was discovered using mobile electrocardiogram screening by the pharmacist. Patients receiving early intervention were prescribed an OAC by a pharmacist using guideline-based algorithms, while patients in the delayed intervention group were referred to their primary care physician for further care. Primary care physicians (PCPs) were sent notification of a patient with actionable AF along with an active medication list. Patients in the delayed intervention group who did not have optimal OAC therapy by 3 months from their PCP received the same pharmacist intervention as the early intervention group did at baseline. Pharmacists were from community pharmacies in Canada with at least one pharmacist with independent prescribing authority and access to electronic health records. The primary outcome was the difference in the rate of optimal OAC use (ascertained by blinded pharmacist) between the two groups at 3-month follow-up.
Results:
A total of 80 patients with actionable AF were enrolled, of which 9 (11.3%) were newly diagnosed. The remaining 71 patients had undertreated AF (5 nonprescription, 66 suboptimal dosing [17 with warfarin and 49 with a direct OAC]). The mean age was 79.7 ± 7.4 years, and 45 patients (56.3%) were female. The median CHADS2 score was 2 (interquartile range, 2-3). Seventy patients completed the study through follow-up. More patients in the early intervention group had optimal OAC use at 3 months compared to the delayed intervention group: 92.3% (36/39 patients) vs. 56.1% (23/41 patients), p < 0.001. The absolute increase in optimal OAC therapy was 34% with early pharmacist intervention and a number needed to treat of 3. The PCP called the pharmacist for prescribing advice in 6 of the 23 patients (26.1%) in the delayed intervention group with optimal OAC therapy at 3 months.
Of the 18 patients in the delayed intervention group who were not receiving optimal OAC therapy at 3 months, 7 patients received pharmacist intervention, while 11 patients did not (4 declined, 2 no longer met inclusion criteria, and 5 were lost to follow-up). At 6 months, all 7 patients with delayed pharmacist intervention were receiving optimal OAC. There was no difference in OAC adherence at 12 months between early and delayed intervention groups (91.4% vs. 89.3%, p = 0.84).
Conclusions:
In this study, pharmacist-led prescribing of OAC resulted in a significant increase in appropriate stroke risk reduction therapy for AF. This model demonstrates a potentially high-yield opportunity to reduce the risk of stroke by improving rates of optimal OAC prescribing for patients with AF.
Perspective:
Despite OAC therapy being widely available and highly effective for stroke risk reduction and improved survival for patients with AF, significant gaps persist in delivery of optimal OAC therapy, leaving a large proportion of patients at unnecessary risk for stroke and its sequelae. Evidence exists that indicates pharmacist-based interventions for optimizing cardiovascular disease care can lead to improved clinical outcomes. Pharmacists are well equipped to address common gaps in delivery of OAC therapy including nonprescription, inappropriate medication choice, or suboptimal dosing. This study highlights an important opportunity for community-based pharmacists to improve rates of optimal OAC therapy and reduce the risk of stroke for patients with AF.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiovascular Care Team, Vascular Medicine
Keywords: Anticoagulants, Atrial Fibrillation, Stroke
< Back to Listings
