Sandhu, Roopinder (Department of Medicine, University of Alberta)
Finlay A. McAlister
Canadian Stroke Prevention Intervention Network
1. The Health Problem/Issue
Atrial fibrillation (AF) is a common condition involving an irregular rhythm of the heart. The most devastating complication of AF is stroke. The stroke caused by AF is often more severe, costly to treat, and associated with a high risk of death. Blood thinners such as warfarin, and newer agents (dabigatran, rivaroxaban, apixaban) prevent blood clots from forming in the heart and traveling to the brain, which results in stroke.
Despite the ability to recognize who is at risk of stroke and would benefit from blood thinners and strong evidence that blood thinners are effective and safe to use, they are under-utilized. The public health consequences of untreated AF are enormous; therefore, alternative strategies to deliver stroke prevention therapy need to be explored. One possible strategy is a greater involvement of pharmacists as providers of health care. Pharmacists are highly accessible, experts in drug therapy, and are expanding their scope of practice to prescribe independently.
2. The Objectives
The overall objective of this project is to increase the appropriate use of blood thinners in patients with AF.
3. The Approach
We will perform our study in Alberta because pharmacists have the ability to access electronic medical records, order and interpret labs tests, and it is the first province to allow independent prescribing for pharmacists. We will screen patients presenting to the pharmacy to identify patients with unrecognized AF and/or known AF but not taking blood thinners and randomize care to either the pharmacist or enhanced usual care (family physician notification by pharmacist).
Using this study design, we will determine the proportion of patients with AF who should be on blood thinners but are either not on or their existing blood thinner prescriptions require adjustment due to drug-drug interaction, contraindications, or sub-optimal levels. We will also determine the rate of optimal blood thinner use at 3 months in those with AF randomized to pharmacist care versus enhanced usual care.
4. The Unique Factors
No interventions for AF have been shown to improve survival and reduce serious morbidity beyond blood thinners for stroke prevention. Effective and safe therapies exist to prevent stroke caused by AF. To our knowledge, this will be the first study to generate new knowledge on a new stroke prevention strategy to increase use of blood thinners in AF patients by empowering an infrastructure already in place, namely improving the integration of pharmacists into the health care team.
5. How the project is relevant to the objectives of the initiative
AF is the cause of 15% of all strokes, with an estimated 15,000 new stroke in Canada each year due to AF. Stroke due to AF is more often more disabling and is associated with a high risk of death. Furthermore, AF can cause heart disease such as pump failure. Our study proposes to evaluate a strategy for recognizing patients with AF and optimizing their treatment before a complication and is therefore relevant to heart and stroke health.
6. The Impact
Our study could identify a new strategy to increase use of blood thinners in AF patients at risk of stroke that could be implemented among prescribing pharmacists across Canada with an immediate impact on stroke prevention.