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Correspondence author: Leona A Ritchie, Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, University of Liverpool, Liverpool, L7 8TX, United Kingdom, Tel: 0151 706 4070
Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, United KingdomDepartment of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, United Kingdom
Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, United KingdomDepartment of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, United KingdomClinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, L3 3AF, United Kingdom
Musculoskeletal and Ageing Science, Institute of Life Course & Medical Sciences, University of Liverpool, L7 8TX, United KingdomLiverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, United Kingdom
Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, United KingdomDepartment of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, United KingdomLiverpool Heart & Chest Hospital, Liverpool, L14 3PE, United KingdomAalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, DK-9220, Denmark
Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, United KingdomDepartment of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L7 8TX, United KingdomLiverpool Heart & Chest Hospital, Liverpool, L14 3PE, United KingdomAalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, DK-9220, Denmark
Within Europe and the Asia-Pacific, the Atrial Fibrillation Better Care (ABC) pathway is the gold standard integrated care strategy for atrial fibrillation management. Atrial fibrillation diagnosis should be Confirmed and Characterized (CC) before implementation of ABC pathway components: (1) ‘A’- Anticoagulation/Avoid stroke; (2) ‘B’- Better symptom management and (3) ‘C’- Cardiovascular and other co-morbidity optimization. Pharmacists have the potential to expedite integrated care for atrial fibrillation across the healthcare continuum -hospital, community pharmacy and general practice. This review summarizes the available evidence base for pharmacist-led implementation of the ‘CC to ABC’ model.
Pharmacists are a potentially untapped resource in relation to Atrial Fibrillation Better Care pathway delivery across the healthcare continuum of hospital, community pharmacy and general practice
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Most research has focused on pharmacist interventions to implement pathway components in isolation, particularly ‘A - Anticoagulation’
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The pharmacy service framework needs re-structuring to support translation of pharmacist interventions into everyday clinical practice, and with scope for these to include prescribing
Introduction
Integrated care for atrial fibrillation has been advocated for over a decade, with different models proposed. The Atrial Fibrillation Better Care (ABC) pathway was first proposed in 2017 as a framework for integrated care to align generalist and specialist atrial fibrillation management across primary and secondary care settings.
The pathway is comprised of three components: (1) ‘A’- Anticoagulation/Avoid stroke; (2) ‘B’- Better symptom management and (3) ‘C’- Cardiovascular and other co-morbidity optimization.
Currently, the ABC pathway is recommended as the ‘gold-standard’ atrial fibrillation management strategy in the latest European Society of Cardiology and Asia-Pacific guidelines.
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
The European guidelines also highlight two steps that precede ABC pathway implementation, providing a complete model for integrated atrial fibrillation care, ‘CC to ABC’.
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
This consists of ‘C’- Confirming the atrial fibrillation diagnosis with a 12-lead electrocardiogram (ECG) or single-lead ECG tracing of ≥30 seconds, followed by ‘C’- Characterization of atrial fibrillation including stroke risk, symptom severity, severity of atrial fibrillation burden and substrate severity.
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
With definitive guidance on what integrated care model to follow, the next consideration is whether pharmacists could help operationalise it. As medicines experts, pharmacists screen and optimize medication prescriptions to ensure safety and effectiveness. In addition, pharmacist prescribers can initiate and modify medications, and monitor for their effect. With this skillset, pharmacists have the potential to implement integrated atrial fibrillation care across the healthcare continuum of hospital, community pharmacy and general practice (Figure 1). This narrative review summarizes the findings from research studies of pharmacist interventions that can be mapped to the ‘CC to ABC’ model. The aim is to determine what role pharmacists could adopt in the delivery of integrated atrial fibrillation care.
Figure 1Roles pharmacists could adopt in the delivery of integrated atrial fibrillation care across the healthcare continuum – hospital, general practice and community pharmacy.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Pharmacist or student (with pharmacist supervision) screening (ECG only), ECG over-read by cardiologist within 48 hours, participants contacted if atrial fibrillation detected, advised to self-refer to GP
Community pharmacy (1), nursing home (1), hospital outpatient cardiology clinic (1)
a223 b66 ± 15 c131 (64%)
Pharmacist screening (brief medical history, pulse palpation, ECG), ECG over-read by cardiologist, if irregularities, advised to seek follow-up with doctor (community pharmacy), directly referred to physician (nursing home), or 12-lead ECG immediately reviewed by cardiologist (hospital outpatient cardiology clinic)
Pharmacist or pharmacy staff initial screening (brief medical history, alcohol consumption questionnaire [Audit-C], atrial fibrillation detecting BP monitor) and if possible atrial fibrillation, ECG obtained and over-read by cardiologist if atrial fibrillation detected again
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
a1145 b77.2 ± 6.8 (unrecognised or undertreated atrial fibrillation), 74.6 ± 6.8 (no atrial fibrillation) c677 (59.1%)
Volunteer or research staff screening (brief medical history, ECG over-read by cardiologist, two automated BP readings [PharmaSmart], Canadian Diabetes Risk Assessment Questionnaire), participant education and opportunity to speak to pharmacist
BP, blood pressure; CAPTURE-AF, Community pharmacy led atrial fibrillation detection and referral service; CHA2DS2-VASc score, score of 1 point each for congestive heart failure, hypertension, female, age 65-74 years, diabetes mellitus, vascular disease and 2 points for previous stroke/transient ischaemic attack/thromboembolism and age ≥75 years; ECG, electrocardiogram; Elba-AF, screening of undiagnosed atrial fibrillation on the Isle of Elba; GP, General Practitioner; PDAF, Pharmacists detecting atrial fibrillation; PIAFF-Pharmacy, Program for the identification of “actionable” atrial fibrillation in the pharmacy setting; SEARCH-AF, Stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
In one study, the AliveCor Kardia mobile single-lead ECG was only performed if abnormalities were first detected by a blood pressure (BP) monitor (Microlife AFIB).
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
a cardiologist was an integral part of the screening programme and had responsibility for interpreting single-lead ECG recordings before follow-up was arranged with the participant's physician,
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
reported the inter-rater agreement between the pharmacist, cardiologist and the AliveCor KardiaMobile algorithm interpretation of single-lead ECG recordings. In one study, the interrater agreement (Cohen's kappa [κ]) was 0.56 between the pharmacist and mobile algorithm, and 0.70 between the cardiologist and mobile algorithm.
In the other study, inter-rater agreement was reported as Cohen's κ 0.69 (95% confidence interval [CI] 0.56-0.82) between the pharmacist and cardiologist, and 0.72 (95% CI 0.60-0.85) between the mobile algorithm and cardiologist.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Incremental savings of approximately £120 million using the AliveCor KardiaMobile device and £50 million using pulse palpation were predicted on the basis that screening was applied to all patients in England and Wales ≥65 years old, with 50% uptake of screening and newly detected atrial fibrillation.
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
In the other study, an incremental cost-effectiveness ratio, based on 55% of warfarin prescription adherence, was reported as $AUD 30,481 (€15,993; $USD 20,695) for preventing one stroke.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Physician-pharmacist atrial fibrillation warfarin clinic, joint determination of INR target, drug dosage, treatment course, date of next visit. Pharmacist delivered patient education, assessment of TTR and INR at follow-up, dose adjustments as needed vs. general clinic (control)
Significantly higher proportion of participants achieved a TTR ≥60% (intervention 73.7% vs. usual care 47.1%, p=0.002).
Pharmacist-led warfarin management for atrial fibrillation patients with TTR <50%, 12-week programme (education, dispensing, INR monitoring, dose adjustment, adherence/adverse event assessment). Pharmacist visits once weekly for 4 weeks, then according to INR monitoring. After week 12, medical team provide care without pharmacist presence
Significant difference in basal, 12-week and one year mean TTR within low-, medium- and high- warfarin adherence groups (low: 15.8% ± 17.4 vs. 35.9% ± 19.9 vs. 46.7% ± 20.8, p <0.001; medium: 11.7% ± 15.9 vs. 49.0% ± 23.5 vs. 51.7 ± 20.9, p <0.001; high: 13.7% ± 15.8 vs. 61.4% ± 21.5 vs. 60.8% ± 22.6, p<0.001).
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
Pharmacist-led AMS with efforts to improve warfarin therapy for atrial fibrillation patients, specifically TTR vs. pharmacist-led AMS before efforts were made to improve warfarin therapy (control)
Significantly higher TTR after efforts were made as part of the pharmacist-led AMS (70.5% vs. 63.4%, p <0.001)
Pharmacist and physician vs. physician only (control) guidance on warfarin treatment for atrial fibrillation patients with chronic kidney disease
TTR (defined as PT-INR 1.6-2.6) significantly higher in pharmacist and physician group vs. physician only group (76.8% ± 15.6 vs. 55.9% ± 25.1, p= 0.005)
Pharmacist (confirmation of drug-drug interactions, monitoring bleeding/PT-INR, dose adjustment recommendations, patient education - lifestyle precautions, warfarin-food interactions) and physician (oral instructions with lifestyle guidance generally omitted) management of atrial fibrillation patients with HF vs. physician only management (control)
TTR (defined as PT-INR 1.6-2.6) significantly higher in pharmacist and physician group vs. physician only group (73.8% [61.4-93.4] vs. 59.8% [44.2- 77.4], p=0.017)
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Pharmacist and physician-led WMTAC for atrial fibrillation patients. Pharmacists responsible for patient education/counselling and implementation of a treatment protocol, recommendations made for dose adjustments/continuation of warfarin therapy vs. physician-led WMTAC with referral to pharmacist only when necessary (control)
No significant difference in TTR between pharmacist and physician-led WMTAC vs. physician-led WMTAC (63.97% ± 19.41 vs, 59.25% ± 20.74, p=0.120)
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
No significant difference in thromboembolic (intervention 5.3% vs. control 5.3%, p=1.000) or bleeding events (intervention 3.5% vs. control 4.3%, p=1.000)
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Remote pharmacist-led management of atrial fibrillation patients taking rivaroxaban. Education, drug administration and observation of drug interactions, weekly adverse event monitoring vs. usual care by cardiologists or primary care providers (control)
No significant difference in thrombosis, heart failure, left atrial dilation. Significant reduction in incidence of gastrointestinal bleeding (intervention 6.1% vs. control 12.4%, p=0.038), skin ecchymosis (intervention 0.6% vs. control 4.5%, p=0.018)
Pharmacist-led AMS for atrial fibrillation patients on NOACs. Initial patient education, phone calls (discuss stroke or bleeding concerns, adherence and provide reminders about required blood tests) or chart reviews vs. other providers - neurologists, cardiologists and primary care providers (control)
No significant difference in the composite endpoint of thromboembolism, bleeding, and all-cause mortality between intervention vs. control (HR 1.25, 95% CI 0.70–2.24)
Implementation of a pathway (SAFE) developed by pharmacists and physicians for patients with new atrial fibrillationdiagnoses (step 1: assessment of contraindications to OAC; step 2: stroke risk assessment with CHADS65; step 3: OAC dosing if indicated). Pathway triggered referral to atrial fibrillation clinic, letter for family physician and follow-up call from pharmacist
65/73 (89%) participants reached 90 days follow-up, one report of gastrointestinal bleeding in participant taking OAC, and one report of stroke in participant who refused OAC
See Phelps 2018, Quality of warfarin therapy (TTR)
Significantly lower odds of the composite endpoint of clinically-relevant bleeding, thromboembolism and all-cause mortality associated with pharmacist-led anticoagulant management (adjusted OR 0.69, 95% CI 0.54-0.87)
Non-profit, integrated healthcare delivery organisation (1), comprised of hospitals (14), outpatient facilities (>200), and a centralised laboratory (1), cohort study
a32074 b72.2 ± 10.7 c13645 (42.5%)
Pharmacist-led anticoagulation clinic for atrial fibrillation patients on warfarin (approximately weekly for first three months of treatment and every three weeks after six months). Pharmacists responsible for monitoring, dose adjustment and reversal, triage of related adverse events, drug interaction interventions, telephone counselling
No significant difference in stroke or systemic embolism event rates between patients with TTR <65% who received frequent pharmacist interventions (≥24 times per year) and patients with TTR <65% who received less frequent interventions (1.88 vs. 1.54 per 100 person-years, respectively, p=0.780)
Pharmacist anticoagulation clinic for dabigatran (patient education on adherence, tolerance issues, storage and refill at initial consultation). Follow-up at two weeks, one month and three months vs. usual care (control)
No significant difference in frequency of minor (p=0.148) or major bleeding events (p=0.516) between pharmacist anticoagulation clinic for dabigatran and usual care
Community pharmacy (†), randomised controlled trial
a370 (estimate) b† c†
Community pharmacist initiates/adjusts OAC therapy in atrial fibrillation patients vs. enhanced usual care -community pharmacist refers atrial fibrillation patients to physician for OAC therapy (control)
Proportion of participants receiving optimal OAC therapy (pending, study ongoing)
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
Multidisciplinary heart failure clinic (1), general outpatient clinic (1), cohort study
a307 b† c†
MDT follow-up of cardiologists, nurses and pharmacists for atrial fibrillation patients vs. cardiologist-only follow-up (control)
Inappropriate anticoagulant use less likely with MDT follow-up (8% vs. 22%). Prescription of VKA in NOAC-eligible patients and incorrect NOAC dosing were the most common reasons for inappropriate use
One-to-one education with pharmacist during admission new atrial fibrillation patients, provision of atrial fibrillation brochure to promote shared decision making about OAC therapy vs. usual care provided pre-intervention (control)
Significant improvement in the appropriateness of OAC therapy (intervention 92% vs. control 36%, p <0.001)
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Pharmacist assessment of appropriateness of initiating OAC in atrial fibrillation patients identified with CHA2DS2-VASc score ≥2 and no OAC prescription within 12 months, escalation to primary care provider as needed vs. usual care (control)
432/1727 (25%) participants potentially eligible for OAC. After pharmacist screening, 75/432 (17%) escalated to the primary care provider. No significant increase in proportion of OAC prescriptions (intervention 4.1% vs. control 4.0%, p=0.860)
Pharmacist review of patient records to confirm documentation supporting absence of OAC in patients with atrial fibrillation /atrial flutter. Pharmacist contact with physician to request review to initiate OAC or document reason for no treatment
349/489 (71.4%) patients had warfarin initiated or clear documentation to explain reason for the absence of OAC therapy after pharmacist review
AMS for new atrial fibrillation patients started on NOACs, generally led by pharmacists
Improvement in correct NOAC dosing when compared to other fee-for-service non-integrated systems. 4735/5060 (93.6%) new atrial fibrillation patients prescribed rivaroxaban or dabigatran at the correct dose, 86/5060 (1.7%) overdosed and 239/5060 (4.7%) under-dosed
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Pharmacist identification of atrial fibrillation patients not on OAC or on antiplatelet monotherapy using patient records and APL- AF software, review of medical records to confirm atrial fibrillation diagnosis, blood results and patient characteristics with initiation of OAC therapy (warfarin or NOACs) when indicated vs. usual care provided pre-intervention (control)
Significant increase in proportion of atrial fibrillation patients prescribed OAC from 62% to 80%, p <0.001
Pharmacist-led virtual clinics with GPs to identify atrial fibrillation patients with a CHA2DS2VASc score ≥2 not anticoagulated vs. usual care provided pre-intervention (control)
Increased prescription of anticoagulation for atrial fibrillation patients in two CCGs from 73% (pre-intervention) to 83% (post-intervention), and from 72% to 78%
Pharmacist treatment recommendations made to GP for atrial fibrillation patients with CHA2DS2-VASc score ≥1/≥2 (male/female) and no anticoagulant prescription
202/497 participants (40.6%) suitable for anticoagulation, 103/202 (51%) commenced on anticoagulant (76/202 refused, 16/202 failed to attend, 7 commenced treatment in secondary care), 85/103 (83%) switched from antiplatelet to anticoagulant
Pharmacist-led anticoagulant review clinic (weekly, four-hour clinic for six months) targeted at atrial fibrillation patients on VKA with TTR <65%
65/87 (74.7%) switched from VKA to NOAC, 63/87 continued on NOAC at two-week follow-up, 1/87 had VKA discontinued (haemorrhagic risk outweighed benefit), 21/87 (24.1%) remained on VKA
Pharmacist assessment of dabigatran and rivaroxaban prescribing using Medication Appropriateness Index tool adapted for NOAC prescribing with recommendations made to physicians
34/69 (49%) inappropriate criteria for treatment, 48 pharmacist interventions, 94% accepted by physicians
Pharmacist stroke risk assessment in atrial fibrillation patients, antithrombotic therapy recommendations to physicians vs. usual care provided pre-intervention (control)
Significant increase in warfarin use from 43% to 58% p=0.050, significant decrease in aspirin use from 48% to 39%, p=0.040 from admission to discharge in intervention group, no significant change in antithrombotic use from admission to discharge in usual care
Pharmacist review of antithrombotic prescribing in atrial fibrillation patients, assessment of bleeding risk factors, interacting medicines, direct patient interview, treatment recommendations made to physicians vs. usual care provided pre-intervention (control)
No significant difference in antithrombotic use (70.8% intervention vs. 67.3% control, p=0.580), significant difference in proportion of patients with antithrombotic discharge plan (88.3% intervention vs. 73.5% control, P <0.01), significantly higher odds of planned or actual warfarin use with intervention (aOR 2.46, 95% CI 1.63-3.74)
Pharmacist identification of atrial fibrillation patients, consultation with patients, caregivers and MDT to obtain information for application of evidence-based algorithm to determine appropriate antithrombotic, discussion with clinical team at ward rounds/case conferences before final treatment decisions made
78/218 (35.8%) had changes made to antithrombotic prescribed pre-intervention (at admission); 60/78 (76.9%) treatment upgrade (no therapy/antiplatelet to anticoagulant), significant overall increase in antithrombotic use pre-intervention vs. post-intervention (at discharge), 59.6% vs 81.2%, p <0.001
Ambulatory care clinic (delivered by cardiologists and primary care physicians) for atrial fibrillation patients with access to a pharmacist‐staffed AMS vs. ambulatory care clinic without access (control)
Significant difference in warfarin use between clinic with access to pharmacist-staffed AMS vs. clinic without access (77.9% vs. 61.7%, p=0.030), access to pharmacist-staffed AMS was an independent predictor of warfarin use (adjusted OR 2.19, 95% CI 1.05-4.56)
Medication adherence, knowledge and patient satisfaction
Significant improvement in patient satisfaction measured using a standard satisfaction survey based on a Likert scale (intervention 68% vs. control 25%, p <0.001)
Pharmacist implementation of evidence-based pharmaceutical care model. Pharmacists consider patients’ preferences, search and evaluate literature, provide objective suggestions to hospitalised atrial fibrillation patients taking rivaroxaban vs. implementation of a general pharmaceutical care model (control)
Satisfaction (14.6 ± 0.9 vs.13.8 ± 1.0, p <0.01) and cognition scores (22.6 ±2.2 vs 20.8 ± 3.0, p <0.01) measured using a questionnaire designed by the researchers significantly higher in patients in intervention group
Pharmacist delivered education and counselling to atrial fibrillation patients taking NOACs
Increased patient knowledge (assessed using five questions) of atrial fibrillation and NOAC use from 3.7/5 (baseline) to 4.3/5 (4 month follow-up), increased medication adherence from 93% (baseline) to 98% (4 month follow-up), P <0.001
Veterans Health Administration sites (67), mixed-method study
a4863 b†** c†**
Pharmacist review of dabigatran prescriptions for atrial fibrillation patients, patient education, adverse event and adherence monitoring
Pharmacist patient education had no effect on dabigatran adherence (adjusted RR 0.94, 95% CI 0.83-1.06), significant association between pharmacist-led monitoring on dabigatran adherence (adjusted RR 1.25, 95% CI 1.11–1.41)
No effect on mean medication possession ratio (intervention 93.1% vs. control 88.3%), no effect on the proportion of participants achieving a medication possession ratio ≥80% (intervention 25% vs. usual care 10%, p=0.160)
AMS, anticoagulant management service; APL-AF, Active Patient Link – Atrial Fibrillation; CCG, clinical commissioning group; CHADS65 score, Canadian algorithm which recommends anticoagulation for most people aged 65 years old and for younger patients with congestive heart failure, hypertension, age, diabetes, stroke/transient ischemic attack score of 1; CHA2DS2-VASc score, score of 1 point each for congestive heart failure, hypertension, female, age 65-74 years, diabetes mellitus, vascular disease and 2 points for previous stroke/transient ischaemic attack/thromboembolism and age ≥75 years; CI, confidence interval; ECG, electrocardiogram; GP, general practitioner; HF, heart failure; HR, hazard ratio; MDT, multidisciplinary team; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; OR, odds ratio; PIAAF-RX, The Improving Stroke Prevention in Atrial Fibrillation Through Pharmacist Prescribing study; PT-INR, prothrombin time – international normalised ratio; RR, relative risk; TTR, time in therapeutic range; VKA, vitamin K antagonist; WMTAC, warfarin medication therapy adherence clinic
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Most studies reported differences in TTR between the pharmacist intervention and control group, with three reporting significantly higher TTR in the intervention group compared to controls.
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
One study found a significantly higher proportion of participants with TTR ≥60% in the physician-pharmacist atrial fibrillation warfarin clinic compared to those who attended a general clinic (73.7% vs. 47.1%, p=0.002).
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Another study implemented a 12-week pharmacist management programme for atrial fibrillation patients with a TTR <50%. Participants were categorised by warfarin adherence (low: two or more missed doses; medium: one missed dose; high: no missed doses).
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
and found a pharmacist-led anticoagulant management services focused on TTR improvement was associated with lower odds of a composite endpoint of clinically-relevant bleeding, thromboembolism and all-cause mortality (adjusted odds ratio [OR] 0.69, 95% CI 0.54-0.87).
A cohort study of 460 participants (intervention n=90, control n=370) carried out at an Academic Healthcare System found no association between pharmacist-led management of patients taking NOACs and the same composite endpoint (Table 2), although the study was limited by low statistical power.
One cohort study of pharmacist-led rivaroxaban management for atrial fibrillation patients found no association with heart failure, left atrial dilation or thrombosis, but a significantly lower incidence of bleeding events when compared to patients under the care of cardiologists or primary care providers (gastrointestinal: 6.1% vs. 12.4%, p=0.038; skin ecchymosis 0.6% vs. 4.5%, p=0.018).
Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.
Physician-Pharmacist Collaborative Clinic Model to Improve Anticoagulation Quality in Atrial Fibrillation Patients Receiving Warfarin: An Analysis of Time in Therapeutic Range and a Nomogram Development.
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
Inappropriate OAC use was reported to be less likely in atrial fibrillation patients who received multidisciplinary follow-up (cardiologist, nurse, pharmacist) compared to cardiologist only follow-up (8% vs. 22%).
Brouillette F. Inappropriate use of anti-thrombotic therapy in patients with atrial fibrillation in a general cardiology outpatient clinic versus a multidisciplinary heart failure team. European Society of Cardiology Heart Failure 2021 Online Congress2021.
were also associated with improved appropriateness of OAC therapy (Table 2). One small cohort study (n=87) found pharmacist-led clinics targeting patients with suboptimal vitamin K antagonist (VKA) therapy (TTR <65%) promoted review of anticoagulant therapy, with 65 participants (74.7%) switched from VKA to NOAC.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
pharmacists were responsible for independently reviewing medical records to identify patients with atrial fibrillation not prescribed anticoagulation. Only three studies explored whether this translated into increased OAC prescribing.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
One randomised controlled trial (RCT) of 1,727 participants found no significant difference in the proportion of OAC prescriptions between intervention and usual care groups (Table 2).
Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
European Journal of Hospital Pharmacy.2018; 25 (A49-A)
In a before-and-after study of 68 participants taking dabigatran, there was no significant difference in the proportion of participants with a medication possession ratio (number of dispensed doses in a specified time period divided by the total number of days in that time period) ≥80% (Table 2).
A larger mixed-method study (n=4,863) also found no significant association between pharmacist education and dabigatran adherence (adjusted relative risk [aRR] 0.94, 95% CI 0.83-1.06).
In contrast, another educational intervention significantly increased medication adherence from baseline to 4-months and marginally improved patient knowledge about AF and NOAC.
(Table 3). In one small cohort study (n=360), pharmacists identified most (89%) sotalol prescriptions were inappropriate based on patients’ renal function and recommended changes to physicians, but only 38% of recommendations were implemented.
In another study, pharmacists led an anti-arrhythmic outpatient clinic for sotalol loading (oversight from electrophysiologist) to determine feasibility compared to inpatient sotalol loading.
Pharmacy-led outpatient clinic using the AliveCor Kardia Mobile ECG to deliver sotalol loading (electrophysiologist oversight) vs. inpatient sotalol loading (control)
Inpatients administered 120mg twice daily, 88.3% outpatients received this dose (three received different doses at electrophysiologist discretion (n=2), or because of prolonged baseline QT interval (n=1)
a36 b75 ± 8.9 dose appropriate or accepted dose adjustment, 78 ± 7.6 partial dose adjustment or no adjustment c†
Pharmacist assessment of sotalol prescribing for atrial fibrillation patients according to renal function, physician prescribing recommendations made when appropriate
Pharmacist recommendation of drug discontinuation/ dose amendment in 32/36, accepted for 12/32 (appropriate therapy) but not for 20/32 (inappropriate therapy), no effect on all-cause hospital re-admission rates at six months for patients on appropriate therapy (31% vs. 55%, p=0.095)
‘ABC’: multi-faceted pharmacist interventions covering two or more components of the Atrial Fibrillation Better Care pathway
Three before-and-after studies explored pharmacist implementation of multi-faceted interventions aligned with ≥2 components of the ABC pathway (Table 4).
One before- and- after study (n=300) examined an AF-specific medication assessment tool (MAT-AF), focused on appropriate OAC dosing by renal function, and necessary monitoring of rate or rhythm controlling agents.
Use of the medication tool was associated with significantly higher odds of OAC and rate control prescriptions (OR 4.07, 95% CI 2.12-7.82 and OR 3.92, 95% CI 1.06-14.54, respectively).
In another study, pharmacists used Active Patient Link (APL-AF) software to identify AF patients potentially eligible for OAC therapy and invited them to attend a general practitioner (GP)-pharmacist clinic.
The clinic initiated OAC therapy where appropriate, and optimized antihypertensive/lipid-lowering therapy. The intervention was associated with a significant increase in OAC prescription (77% to 83%) and the proportion of patients with a serum cholesterol <5mmol/L, although this did not translate into a significant increase in statin use. Data on dosage changes to statin therapy are not reported.
Delivery of a protocol for atrial fibrillation care post-hospital discharge that comprised rate control, stroke prevention and risk factor assessment and modification was associated with significantly higher odds of discharge from the hospital emergency department (OR 4.2, 95% CI 1.9-9.8), but no significant reduction in hospital length of stay for subsequent admissions.
Table 4. Characteristics of studies of pharmacist-led educational or multi-faceted interventions covering two or more components of the ABC pathway for atrial fibrillation.
Author (study name), year, country
Study setting, (n), study design
Intervention/controlaSample sizebAge (median [IQR], or mean ± SD)cProportion of females, n (%)
Description of intervention and control (where applicable)
Main outcomes of intervention
Multi-faceted interventions covering two or more components of the ABC pathway
Pharmacist identification of atrial fibrillation patients potentially eligible for anticoagulation using patient records and APL-AF software, patient invitation to GP-pharmacist consultation with anticoagulant initiation, optimization of BP/lipid therapy where appropriate, discussion of complex patients at weekly MDT (cardiologist, haematologist, GP with specialist interest in cardiology, GP co-ordinator and pharmacist) vs. usual care provided pre-intervention between April 2016/17 (control)
Significant increase in proportion of atrial fibrillation patients prescribed anticoagulation from 2016/17 to 2017/18 (77% to 83%, p <0.0001), non-significant increase in use of statins (66.8% to 68.1%), but significant increase in serum cholesterol reported as <5mmol/L (64.2% to 68%, p=0.012), no significant difference in proportion of patients with blood pressure ≥140/90mmHg (2.9% to 3.2%)
Pharmacist implementation of MAT-AF to assess appropriateness of antithrombotic, rate and rhythm therapy for atrial fibrillation patients vs. usual care provided pre-intervention (control)
Significantly higher odds of prescription of oral anticoagulants (OR 4.07, 95% CI 2.12-7.82, p <0.001), rate-control (OR 3.92, 95% CI 1.06-14.54, P=0.041), digoxin monitoring (OR 10.40, 95% CI 3.59-30.10, P <0.001), referral of patients on anti-arrhythmic drugs not in sinus rhythm to cardiology (OR 8.00, 95% CI 1.13-56.79, P=0.038)
Pharmacist-led atrial fibrillation clinic (cardiologist/electrophysiologist supervision) for patient follow up post-ED discharge after an atrial fibrillation-related admission, pharmacist delivery of protocol for atrial fibrillation care including rate-control and stroke prevention, risk factor assessment and modification, education, coordination of care across teams in primary care and ED vs. usual care provided pre-intervention (control)
Significantly higher odds of discharge from ED (OR 4.20, 95% CI 1.90-9.80) but had no significant difference on hospital length of stay in the event of repeat ED presentations (pre-intervention 3.0 ± 4.6 days vs. post-intervention 2.5 ± 4.4 days, p=0.560)
Implementation of nurse practitioner and pharmacist-centred follow-up programme (AF-QCP) for atrial fibrillation patients discharged from hospital. Tailored patient education, support for self-management, atrial fibrillation care plan for primary care providers, support from cardiologists and internists vs. usual care provided pre-intervention (control)
No difference in repeat ED visits or hospital admissions over 12 months between patients on AF-QCP follow-up programme compared to historic controls
Faith-based institutions (4), before- and- after study
a97 b75.0 ± 13.7 c69 (71.1%)
Pharmacist-led education (70 minute event; baseline assessment of stroke knowledge, study questionnaire, BP and HR readings, presentation, question-and-answer session, post-education questionnaire) for community-dwelling adults
Participants self-reporting atrial fibrillation (n=6) identified atrial fibrillation management as a modifiable stroke-risk factor after pharmacist-led education (none identified it before educational session)
MDT atrial fibrillation clinic led by pharmacists and electrophysiologists to evaluate and implement individualised treatment plans and provide patient education, medication management and follow-up
17/71 (23.9%) clinic patients hospitalised and 2/17 (11.7%) had an ischaemic stroke, reduction in hospital admission rate within one year when compared to reported national admission rates occurring within six months (23.9% vs. 65.8%), study ischaemic stroke rate (2.82%) lower than rates reported in the literature (23.50%)
ABC, Atrial Fibrillation Better Care pathway; AF-QCP, Atrial Fibrillation Quality Care Programme; APL-AF, Active Patient Link – Atrial Fibrillation; BP, blood pressure; CI, confidence interval; ED, emergency department; GP, General Practitioner; HR, heart rate; MAT-AF, medication assessment tool for AF; MDT, multidisciplinary team; OR, odds ratio
A 70 minute pharmacist-led educational session increased the proportion of participants who identified atrial fibrillation as a modifiable stroke risk factor (none identified it pre-education, six identified it post-education).
Research efforts have predominantly focused on pharmacist interventions for anticoagulant management in atrial fibrillation, reporting on appropriateness (guideline-adherent) or prescription rates. Thirteen studies have demonstrated the feasibility of pharmacist-led AF screening in primary care, most commonly using the AliveCor Kardia Mobile single-lead ECG. There is a paucity of research on pharmacist-led characterization or symptom management of atrial fibrillation, or delivery of multifaceted interventions to provide holistic care for AF patients based on the ABC pathway. Extensive heterogeneity among included studies in relation to their design, populations, interventions, outcome measures and statistical analyses limits the conclusions that can be drawn from the available evidence.
Pharmacist-led atrial fibrillation screening programmes appear to have demonstrated feasibility across a variety of clinical and non-clinical settings,
Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study.
1357Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study.
To be valuable, any screening programme must be precise, and there must be a robust infrastructure to support effective and safe referral and follow-up in the event of positive screening.
There is a paucity of cost-effectiveness data to accompany the studies, and use of a cross-sectional design limited study follow-up, for example, not all studies quantified the number of new atrial fibrillation cases. To support implementation of atrial fibrillation screening programmes, studies need to demonstrate that the associated expenditure translates into a reduced burden on health and social care services. Large scale RCTs are underway to address this,
but do not mention the involvement of pharmacists in screening programme delivery. Pharmacists embedded within primary care services (general practice or community pharmacy) could run opportunistic or systematic atrial fibrillation screening programmes.
Arguably, the interventions most suitably aligned to a pharmacist's skillset are those that focus on medication initiation, optimization and education. Pharmacist-led anticoagulant management services comprised of education,
Effect of Standardized Warfarin Treatment Protocol on Anticoagulant Effect: Comparison of a Warfarin Medication Therapy Adherence Clinic with Usual Medical Care.
Impact of a pharmacist-led education and follow-up service on anticoagulation control and safety outcomes at a tertiary hospital in China: a randomised controlled trial.
International Journal of Pharmacy Practice.2020; 28: 97-106
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