Calgary, Alberta—Pharmacists can make a significant difference in decreasing the risk of stroke in patients with undiagnosed or undertreated AF, according to a Canadian study.

University of Calgary researchers sought to determine if pharmacists could increase the delivery of stroke risk reduction therapy in AF patients.

The results published in the Journal of the American Medical Association Network Open reported that the randomized clinical trial of 80 patients with AF and high stroke risk found a 34% absolute increase in appropriate stroke risk reduction therapy with a pharmacist prescription compared with usual care.

“Engagement of community pharmacists is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF,” the authors wrote.

Background information in the article pointed out that significant gaps in the delivery of appropriate OACs exist, which leaves a large percentage of AF patients unnecessarily at risk for stroke and its sequalae.

The study team sought to investigate whether pharmacist-led OAC prescriptions can increase the delivery of stroke risk reduction therapy in those patients.

The researchers performed the prospective, open-label, patient-level randomized clinical trial of early versus delayed pharmacist intervention from January 1, 2019, to December 31, 2022, and was performed in 27 community pharmacies in the Province of Alberta.

For the study, pharmacists identified patients aged 65 years or older with one additional stroke risk factor and known, untreated AF (OAC nonprescription or OAC suboptimal dosing) or performed screening using a 30-second single-lead electrocardiogram to detect previously unrecognized AF. They classified patients with undertreated or newly diagnosed AF eligible for OAC therapy as having actionable AF. Data were analyzed from April 3, 2023, to November 30, 2023.

“In the early intervention group, pharmacists prescribed OAC using guideline-based algorithms with follow-up visits at 1 and 3 months,” the authors advised. “In the delayed intervention group, which served as the usual care control, the primary care physician (PCP) was sent a notification of actionable AF along with a medication list (both enhancement over usual care). After 3 months, patients without OAC optimization in the control group underwent delayed pharmacist intervention.”

The primary outcome was defined as the difference in the rate of guideline-concordant OAC use in the two groups at 3-month follow-up, ascertained by a research pharmacist who was blinded to treatment allocation.

Overall, 80 patients were enrolled with actionable AF (nine [11.3%] newly diagnosed in 235 individuals screened); 70 of them completed follow-up. The patients’ mean (SD) age was 79.7 (7.4) years, and 45 patients (56.3%) were female. The median CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke or transient ischemic attack) score was 2 (interquartile range, 2-3).

The results indicated that guideline-concordant OAC use at 3 months occurred in 36 of 39 patients (92.3%) in the early-intervention group versus 23 of 41 (56.1%) in the control group (P <.001), with an absolute increase of 34% and number needed to treat of three. “Of the 23 patients who received appropriate OAC prescription in the control group, the PCP called the pharmacist for prescribing advice in 6 patients,” the researchers noted.

The randomized clinical trial concluded that pharmacist OAC prescription “is a potentially high-yield opportunity to effectively close gaps in the delivery of stroke risk reduction therapy for AF. Scalability and sustainability of pharmacist OAC prescription will require larger trials demonstrating effectiveness and safety.”

AF is the most common heart rhythm disorder and a leading cause of stroke in aging adults. The authors note that strokes related to AF are more severe and disabling compared with non-AF strokes, but they add that OAC is widely available and highly effective for stroke risk reduction and improving survival in AF.

“However, despite accessible clinical guidelines for identifying individuals with AF who stand to benefit from OAC, major gaps in the delivery of appropriate OAC therapy persist, leaving a large proportion of persons with AF unnecessarily at risk for stroke and its sequalae,” the authors wrote. “Recent advances in OAC therapeutics offer effective drug choices that are safer and more easily administered and managed than warfarin, yet large proportions of the population at risk for AF remain undertreated or untreated. Novel solutions are needed to address persistent gaps in the delivery of OAC therapy for AF.”

The article pointed out that the most commonly reported gaps in delivery of OAC therapy include nonprescription, inappropriate medication, or suboptimal dosing, “all of which can be directly and effectively targeted with pharmacist-based interventions.”

The suggestion that pharmacists led the effort is based on growing evidence that pharmacist-based interventions for optimizing cardiovascular disease care, especially when focused on adherence to guideline-directed therapies, can lead to marked and sustained improvement in clinical outcomes, the research noted.

“The potential for efficacy around AF care is especially promising, as pharmacist-led warfarin anticoagulation clinics have been demonstrated to improve time in the therapeutic range and decrease adverse bleeding events,” the authors added. “Given increasing recognition of both the feasibility and cost-effectiveness of pharmacist-based clinical programs, several countries have moved toward pharmacist prescribing, either independently or through the use of collaborative practice agreements.”

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