Atrial Fibrillation, Stroke
Conditions
Keywords
atrial fibrillation, stroke, oral anticoagulation therapy, pharmacist case management
Brief summary
The purpose of this study is to compare the effectiveness of prescribing oral anticoagulation therapy by pharmacist intervention compared to enhanced usual care in participants with unrecognized AF and/or known AF but not taking blood thinners.
Detailed description
Background: AF is the most common arrhythmia and the leading cause of stroke. Despite robust evidence oral anticoagulation (OAC) therapy is effective and safe for stroke prevention in patients with AF; there is a lack of real-world application. Alternative strategies to deliver stroke prevention therapy need to be explored. Although pharmacists' prescribing of antihypertensive and lipid lowering drug therapy has been shown to increase adherence to guideline-based targets and warfarin management improve control of international normalized ratios in anticoagulation clinics, the role of pharmacist initiation of OAC therapy compared to usual care in AF patients for stroke prevention in a community setting is unclear. In this study, the investigators will screen participants presenting to community pharmacies to identify participants with unrecognized AF and/or known AF but not taking blood thinners or not on optimal OAC therapy and randomize care to either the pharmacist or enhanced usual care (family physician notification by pharmacist).
Interventions
DRUGAnticoagulants
Anticoagulant therapy will be initiated/titrated in patients with atrial fibrillation in accordance with the Canadian Cardiovascular Society Guidelines for Atrial Fibrillation.
Sponsors
Heart and Stroke Foundation of Canada
Canadian Stroke Prevention Intervention Network
University of Alberta
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
PREVENTION
Masking
NONE
Intervention model description
Prospective, open-label, randomized, stepped wedge trial design. Participants will be randomized to early (day 0-90) versus delayed pharmacist intervention (starting day 90-180).
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age ≥ 65 years with one additional stroke risk factor (hypertension, diabetes, heart failure history of or left ventricular ejection fraction \<0.40), previous stroke or transient ischemic attack). * Atrial fibrillation and not on oral anticoagulation (OAC) therapy but eligible * Atrial fibrillation on sub-optimal OAC
Exclusion criteria
* Uncontrolled hypertension (defined as average SBP ≥ 160 mmHg \[2 readings taken at time of screening\]). * End stage renal disease (CrCl \< 15 ml/min) * Valvular Heart Disease including those with prosthetic valve, mitral stenosis (moderate to severe) or valve repair. * Excess alcohol intake (males: ≥ 28 units/week, females: ≥ 21 units/week. One unit of alcohol = 8 oz beer, 1 oz hard liquor or 4 oz wine). * Intracranial bleed at any point. * History of Major Bleeding at any point (defined as overt bleeding at a critical site including intracranial, intraspinal, intraocular, pericardial, or retroperitoneal; or bleed requiring hospitalization). * Foreshortened life-expectancy or severe comorbidities precluding study follow-up period * Unable to read/understand English * Severe cognitive impairment (defined as score ≥ 5 on the Short Portable Mental Status Questionnaire)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Optimal Oral Anticoagulant (OAC) Therapy for Atrial Fibrillation Stroke Prevention | 3 months | Proportion of participants receiving optimal OAC therapy in accordance with the Canadian Cardiovascular Society Guidelines for Atrial Fibrillation in the early intervention arm compared to the delayed intervention arm. Optimal defined as a new prescription for OAC in a previously untreated AF or known AF who should be on an OAC or adjustment of an existing OAC prescription. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Prevalence of AF | Through study completion, an average of 1 year | To determine the prevalence of participants with unrecognized AF eligible for OAC therapy and those with AF who should be on OAC therapy but are either not on or their existing OAC prescriptions; require adjustment due to contraindications, or sub-optimal levels (hereafter referred to those with actionable AF) |
| Patient Satisfaction with Pharmacists Services | 3 months | Assessed using the validated Participant Satisfaction with Pharmacists Services Questionnaire (consists of 22 questions with 4 point Likert scale). |
| Qualitative Assessment of Implementation by Pharmacist | Through study completion, an average of 1 year | Assessed using the questionnaire developed by the SEARCH-AF study |
| Healthcare Utilization | One year | To determine the number of hospital, emergency department and physician visits related to AF |
Countries
Canada
Outcome results
None listed