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Integrated Care for Atrial Fibrillation Management: The Role of the Pharmacist

  • Leona A. Ritchie
    Correspondence
    Requests for reprints should be addressed to Leona A. Ritchie, MPharm, Liverpool Centre for Cardiovascular Science, William Henry Duncan Building, University of Liverpool, Liverpool L7 8TX, UK.
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom
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  • Peter E. Penson
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom

    Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, United Kingdom
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  • Asangaedem Akpan
    Affiliations
    Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom

    Liverpool University Hospitals NHS Foundation Trust, United Kingdom
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  • Gregory Y.H. Lip
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom

    Liverpool Heart and Chest Hospital NHS Foundation Trust, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
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  • Deirdre A. Lane
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool, United Kingdom

    Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom

    Liverpool Heart and Chest Hospital NHS Foundation Trust, United Kingdom

    Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
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Open AccessPublished:August 20, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.07.014

      Abstract

      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) prior to implementation of ABC pathway components: 1) "A"- Anticoagulation/Avoid stroke; 2) "B"- Better symptom management; and 3) "C"- Cardiovascular and other comorbidity optimization. Pharmacists have the potential to expedite integrated care for atrial fibrillation across the health care continuum: hospital, community pharmacy, and general practice. This review summarizes the available evidence base for pharmacist-led implementation of the "CC to ABC" model.

      Graphical Abstract

      Keywords

      Clinical Significance
      • Pharmacists are a potentially untapped resource in relation to Atrial Fibrillation Better Care pathway delivery across the health care continuum of hospital, community pharmacy, and general practice.
      • Most research has focused on pharmacist interventions to implement pathway components in isolation, particularly "A – Anticoagulation/Avoid stroke".
      • 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.
      • Lip GYH
      The ABC pathway: an integrated approach to improve AF management.
      The pathway is comprised of 3 components: 1) "A" – Anticoagulation/Avoid stroke; 2) "B" – Better symptom management; and 3) "C" – Cardiovascular and other comorbidity optimization.
      • Lip GYH
      The ABC pathway: an integrated approach to improve AF management.
      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.
      • Hindricks G
      • Potpara T
      • Dagres N
      • et al.
      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.
      ,
      • Chao TF
      • Joung B
      • Takahashi Y
      • et al.
      2021 Focused update consensus guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: executive summary.
      The European guidelines also highlight 2 steps that precede ABC pathway implementation, providing a complete model for integrated atrial fibrillation care, "CC to ABC".
      • Hindricks G
      • Potpara T
      • Dagres N
      • et al.
      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.
      • Hindricks G
      • Potpara T
      • Dagres N
      • et al.
      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 operationalize 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 skill set, pharmacists have the potential to implement integrated atrial fibrillation care across the health care continuum of hospital, community pharmacy, and general practice (Figure). 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
      FigureRoles pharmacists could adopt in the delivery of integrated atrial fibrillation care across the health care continuum – hospital, general practice, and community pharmacy.
      AF = atrial fibrillation; BP = blood pressure.

      "CC": Confirm and Characterize Atrial Fibrillation: Pharmacist Interventions for Atrial Fibrillation Screening and Characterization

      Thirteen studies have tested the feasibility of pharmacist-led atrial fibrillation screening programs (Table 1).
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      Three of these also attempted to characterize atrial fibrillation by assessing symptoms
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      or using the 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 ischemic attack/thromboembolism and age ≥75 years) to quantify stroke risk.
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      None of these studies have characterized atrial fibrillation by severity of atrial fibrillation burden or substrate severity.
      Table 1Characteristics of Cross-Sectional Studies of Pharmacist-Led Screening for Atrial Fibrillation
      First Author (Study Name), Year, CountryStudy Setting (n)aSample Size

      bAge (Median [IQR], Mean ± SD)

      cProportion of Females, n (%)
      Description of Screening Intervention
      Screening device: AliveCor KardiaMobile single-lead ECG
      Khanbhai (CAPTURE-AF), 2020, UK
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      Community pharmacies (28)a1737

      b
      Not reported.
      (n = 851 were >75 y)

      c846 (48.7%)
      Pharmacist screening (ECG, atrial fibrillation screening tool), specialist team referral if possible atrial fibrillation
      Savickas (PDAF), 2020, UK
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      General practice (4)a604

      b73 [69-78]

      c346 (57.3%)
      Pharmacist screening (pulse palpation, ECG), ECG over-read by cardiologist within 72 h, irregularities reported to GP
      Savickas, 2019, UK
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      Care homes (4)a53

      b90 ±
      Not reported.


      c40 (76%)
      Pharmacist screening (pulse palpation, ECG), ECG over-read by cardiologist within 72 h, irregularities reported to GP
      Zaprutko, 2020, Poland
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      Community pharmacies (10)a525

      b73.72 ± 6.49

      c358 (68.19%)
      Pharmacist or student (with pharmacist supervision) screening (ECG only), ECG over-read by cardiologist within 48 h, participants contacted if atrial fibrillation detected, advised to self-refer to GP
      Anderson, 2020, USA
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      Health fairs (13)a697

      b56 ± 15

      c494 (71%)
      Student pharmacist screening with pharmacist supervision (ECG, CHA2DS2-VASc), advised to seek follow-up with doctor if irregularities
      Cunha, 2019, Portugal
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      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)
      Hazelrigg, 2019, UK
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.


      Public awareness campaigna1144

      b54.99 ±
      Not reported.


      c505 (44.1%)
      Pharmacist and nurse screening (ECG, CHA2DS2-VASc), participant education, 12-lead ECG if irregularities with referral to GP
      Twigg, 2016, UK
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      Community pharmacies (6)c594

      d68.3 ± 8.9

      e
      Not reported.
      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
      Lowres (SEARCH-AF), 2015, Australia
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      Community pharmacies (10)c1000

      d76 ± 7

      e560 (56%)
      Pharmacist screening (brief medical history, pulse palpation, ECG) and ECG over-read by cardiologist
      Screening device: Microlife AFIB (Atrial fibrillation-detecting BP monitor)
      Bacchini, 2019, Italy
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      Community pharmacies (74)a3071

      b73.7 ± 9.2 (screening positive), 66.4 ± 9.9 (screening negative)

      c1855 (60.4%)
      Pharmacist screening and brief medical history, advised to seek follow-up with doctor or attend hospital if irregularities
      Screening device:
      Not reported.
      Lobban, 2018, UK, Portugal, Spain, Canada, New Zealand, France, Hungary, Prague, Switzerland, Australia
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      Community pharmacies (
      Not reported.
      )
      a2573

      b64.71 ± 12.95

      c1773 (68.9%)
      Pharmacist screening (pulse palpation, single-lead ECG where possible, symptom and risk factor assessment), referral to doctor if irregularities
      Screening device: MyDiagnostick single-lead ECG
      Modesti (Elba-AF), 2017, Italy
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      General practice (10), community pharmacies (10)a1000 (target)

      b
      Not reported.


      c
      Not reported.
      Pharmacist screening (brief medical history, ECG)
      Screening device: HeartCheck CardioComm single-lead ECG
      Sandhu (PIAAF-Pharmacy), 2016, Canada
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      Community pharmacies (30)a1145

      b77.2 ± 6.8 (unrecognized 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, 2 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 ischemic 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; PIAAF-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
      low asterisk Not reported.
      Eleven studies
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      ,
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      ,
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      relied on a single-lead electrocardiogram (ECG) recording for the detection of atrial fibrillation using the AliveCor KardiaMobile device (AliveCor Inc., Mountain View, Calif; n = 9),
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      ,
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      ,
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      MyDiagnostick (MyDiagnostick Medical B.V., Maastricht, The Netherlands; n = 1)
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      and HeartCheck (CardioComm Solutions, Inc., North York, Ont, Canada; n = 1).
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      In one study, the AliveCor KardiaMobile single-lead ECG was performed only if abnormalities were first detected by a blood pressure monitor (Microlife AFIB; Microlife AG Swiss Corporation, Widnau, Switzerland).
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      One study did not specify the device used to generate the single-lead ECG,
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      and another study used the Microlife AFIB in isolation to detect atrial fibrillation.
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      Manual pulse palpation was performed in 5 studies,
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      ,
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      ,
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      ,
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      and in one study
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      this was combined with a symptom and risk factor assessment.
      Study settings varied but were predominantly conducted in community pharmacies (n = 7).
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      ,
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      ,
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      ,
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      ,
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      The incidence of new atrial fibrillation was reported in 8 studies
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      ,
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      ,
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      ,
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Lobban T
      • Breakwell N
      • Hamedi N
      • et al.
      1357 Identifying the undiagnosed AF patient through “Know Your Pulse” community pharmacy based events held in ten countries during Arrhythmia Alliance World Heart Rhythm Week 2017.
      ,
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      and ranged from 0.7%
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      to 6.3%.
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      Other studies only reported cases of possible atrial fibrillation,
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      ,
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      ,
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      and no results were available for one study.
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      In 7 studies
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      ,
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      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 program and had responsibility for interpreting single-lead ECG recordings before follow-up was arranged with the participant's physician,
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      • Zaprutko T
      • Zaprutko J
      • Baszko A
      • et al.
      Feasibility of atrial fibrillation screening with mobile health technologies at pharmacies.
      ,
      • Cunha S
      • Antunes E
      • Antoniou S
      • et al.
      Raising awareness and early detection of atrial fibrillation, an experience resorting to mobile technology centred on informed individuals.
      ,
      • Twigg MJ
      • Thornley T
      • Scobie N
      Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service.
      ,
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.
      or jointly by their physician and local atrial fibrillation clinic.
      • Sandhu RK
      • Dolovich L
      • Deif B
      • et al.
      High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme.
      Five studies
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      ,
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      ,
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      ,
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      relied initially on algorithm interpretation of the Microlife AFIB blood pressure monitor,
      • Bacchini M
      • Bonometti S
      • Del Zotti F
      • et al.
      Opportunistic screening for atrial fibrillation in the pharmacies: a population-based cross-sectional study.
      AliveCor KardiaMobile,
      • Khanbhai Z
      • Manning S
      • Fordham R
      • Xydopoulos G
      • Grossi-Sampedro C
      • Hussain W
      Community pharmacy led atrial fibrillation detection and referral service – the Capture AF study.
      ,
      • Anderson JR
      • Hunter T
      • Dinallo JM
      • et al.
      Population screening for atrial fibrillation by student pharmacists at health fairs.
      ,
      • Hazelrigg B
      • Antoniou S
      • Miller M
      Determining pharmacists’ ability to detect atrial fibrillation by utilising mobile single-lead electrocardiogram systems (Alivecor/Kardia) in “Know Your Pulse” awareness campaigns.
      or MyDiagnostick single-lead ECG recording
      • Modesti PA
      • Donigaglia G
      • Fabiani P
      • Mumoli N
      • Colella A
      • Boddi M
      The involvement of pharmacies in the screening of undiagnosed atrial fibrillation.
      to detect abnormalities and determine the need for referral.
      Only 2 studies
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      ,
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a 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.
      • Savickas V
      • Stewart AJ
      • Short VJ
      • et al.
      P6145 Atrial fibrillation screening in care homes by clinical pharmacists using pulse palpation and single-lead ECG: a feasibility study.
      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.
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      Two studies evaluated cost-effectiveness using a National Institute for Health and Care Excellence costing report for atrial fibrillation,
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: a cross-sectional feasibility study.
      or treatment/outcome data from a UK cohort of 5555 patients with incidentally detected asymptomatic atrial fibrillation.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      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.
      • Savickas V
      • Stewart AJ
      • Rees-Roberts M
      • et al.
      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.
      • Lowres N
      • Neubeck L
      • Salkeld G
      • et al.
      Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies. The SEARCH-AF study.

      "A" Anticoagulation/Avoid Stroke: Pharmacist Interventions for Anticoagulant Management

      Thirty studies investigated the effect of pharmacist-led interventions to optimize anticoagulation for stroke prevention in atrial fibrillation
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      Sandhu R. Improving stroke prevention in atrial fibrillation through pharmacist prescribing (PIAAFRx). ClinicalTrials.gov Identifier: NCT03126214. 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT03126214. Accessed February 28, 2020.

      ) (Table 2). Half of the studies (n = 15) were conducted in hospitals,
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      ,
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      ,
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      ,
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      ,
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      ,
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      ,
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      ,
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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 the remainder in outpatient clinics (n = 6),
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      general practice (n = 2),
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      ,
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      non-profit integrated health care delivery systems (n = 2),
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      Veterans Health Administration site(s) (n = 2),
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      ,
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      and an Academic Healthcare System (n = 1).
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      The study setting was not specified in 2 studies.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      ,
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      Studies included patients on warfarin (n = 9),
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      ,
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      ,
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      ,
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      ,
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      non-vitamin K antagonist oral anticoagulants (NOACs) (n = 8)
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      ,
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      ,
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      ,
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      or both (n = 1).

      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      Nine studies referred broadly to anticoagulants,
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      ,
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      ,
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      ,
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      ,
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      ,
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      ,
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
      and 3 evaluated antithrombotics.
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      ,
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      ,
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      Seven studies reported the quality of warfarin therapy, measured by time in therapeutic range (TTR),
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      ,
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      ,
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      ,
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      ,
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      7 reported on health outcomes (thromboembolism, bleeding, mortality),
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      ,
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      ,
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      15 reported on oral anticoagulant (OAC) prescribing,
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      ,
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      ,
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      ,
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      ,
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      ,
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      one on patient knowledge,
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      one on patient cognition,
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      2 on patient satisfaction,
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      and 3 on medication adherence.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      Six of these studies reported on 2 outcomes, including TTR and health outcomes,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      medication adherence and health outcomes,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      patient satisfaction and OAC prescribing,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      patient satisfaction and cognition,
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      and patient knowledge and medication adherence.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      Table 2Characteristics of Studies of Pharmacist Interventions for Anticoagulation in Atrial Fibrillation
      Author (Study Name), Year, CountryStudy Setting (n), Study DesignIntervention/Control

      aSample Size

      bAge (Median [IQR], or Mean ± SD)

      cProportion of Females, n (%)
      Description of Intervention and Control (Where Applicable)Main Findings
      Quality of warfarin therapy (TTR)
      Wang, 2021, China
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      Hospital (1), cohort studya57/208

      b67.1 ± 10.9/70.4 ± 9.5

      c31 (54.4%)/116 (55.8%)
      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 = .002).
      Marcatto
      Marcatto et al have one other publication [Ref 48] that uses the same cohort and reports on TTR at weeks 4 and 12 without a breakdown of different warfarin adherence groups
      , 2021, Brazil
      • Marcatto LR
      • Sacilotto L
      • Tavares LC
      • et al.
      Pharmaceutical care increases time in therapeutic range of patients with poor quality of anticoagulation with warfarin.
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      Hospital (1), cohort studya262

      b
      not reported.


      c
      not reported.
      Pharmacist-led warfarin management for atrial fibrillation patients with TTR <50%, 12-wk program (education, dispensing, INR monitoring, dose adjustment, adherence/adverse event assessment). Pharmacist visits once weekly for 4 wk, then according to INR monitoring. After wk 12, medical team provide care without pharmacist presenceSignificant difference in basal, 12 wk, and 1 y 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 < .001; medium: 11.7% ± 15.9 vs 49.0% ± 23.5 vs 51.7 ± 20.9, P < .001; high: 13.7% ± 15.8 vs 61.4% ± 21.5 vs 60.8% ± 22.6, P < .001).

      Liang, 2019, China
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      Hospital (1), randomized controlled triala77/75

      b60.1 ± 16.3/62.5 ± 14.5

      c36 (46.8%)/31 (41.3%)
      Pharmacist-led warfarin education and follow-up service (2 phone calls days 30 and 90 post-discharge) vs usual care (control)No significant difference in TTR (intervention 35.9% vs usual care 29.5%, P = .203)
      Phelps, 2018, USA
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      Non-profit integrated healthcare delivery system (1), before-and-after studya4764/3641

      b74.6 ± 10.1/73.9 ± 10.6

      c2626 (55.1%)/1948 (53.5%)
      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 < .001)
      Kose, 2018, Japan
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      Hospital (1), cohort studya16/23

      b71.8 ± 2.2/ 72.3 ± 1.8

      c7 (43.8%)/4 (17.4%)
      Pharmacist and physician vs physician-only (control) guidance on warfarin treatment for atrial fibrillation patients with chronic kidney diseaseTTR (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 = .005)
      An, 2017, Japan
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      Hospital (1), cohort studyc25/32

      d70 [64-76.5]/72 [66.3-76.8]

      e13 (52%)/9 (28.1%)
      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 = .017)
      Aidit, 2017, Malaysia
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      Hospital (1), before-and-after studya106/126

      b66.11 ± 10.81 (all participants)

      c80 (53%) (all participants)
      Pharmacist and physician-led WMTAC for atrial fibrillation patients. Pharmacists responsible for patient education/counseling 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 = .120)
      Health outcomes
      Wang, 2021, China
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      Hospital (1), cohort studya57/208

      b67.1 ± 10.9/70.4 ± 9.5

      c31 (54.4%)/116 (55.8%)
      See Wang 2021, Quality of warfarin therapy (TTR)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)
      Li, 2020, China
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      Hospital (1), cohort studya179/202

      b76.3 ± 7.8/75.2 ± 7.1

      c69 (38.5%)/80 (39.6%)
      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 = .038), skin ecchymosis (intervention 0.6% vs control 4.5%, P = .018)
      Jones, 2020, USA
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      Academic Healthcare System (1), cohort studya90/370

      b68.9 ± 11/67.1 ± 12

      c34 (37.8%)/141 (38.1%)
      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)

      Kirwan
      available as abstract only.
      , 2020, Canada
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      Hospital emergency departments (2), cohort studya177

      b70 [61-78]

      c92(52%)
      Implementation of a pathway (SAFE) developed by pharmacists and physicians for patients with new atrial fibrillation diagnoses (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 pharmacist65/73 (89%) participants reached 90-d follow-up, one report of gastrointestinal bleeding in participant taking OAC, and one report of stroke in participant who refused OAC
      Phelps, 2018, USA
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      Non-profit integrated health care delivery system (1), before-and- after studya4764/3641

      b74.6 ± 10.1/73.9 ± 10.6

      c2626 (55.1%)/1948 (53.5%)
      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)
      An, 2017, USA
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      Nonprofit, integrated health care delivery organization (1), comprised of hospitals (14), outpatient facilities (>200), and a centralized laboratory (1), cohort studya32074

      b72.2 ± 10.7

      c13,645 (42.5%)
      Pharmacist-led anticoagulation clinic for atrial fibrillation patients on warfarin (approximately weekly for first 3 mo of treatment and every 3 wk after 6 mo). Pharmacists responsible for monitoring, dose adjustment, and reversal, triage of related adverse events, drug interaction interventions, telephone counselingNo 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 = .780)
      Lee, 2013, USA
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      Outpatient clinic (1), before-and- after studya20/48
      45/48 participants in control group had atrial fibrillation +/- flutter and 3/48 had atrial flutter only, all participants in intervention group had atrial fibrillation +/- flutter


      b78 [72-83]/72 [67-81]

      c0 (0%)/1 (2%)
      Pharmacist anticoagulation clinic for dabigatran (patient education on adherence, tolerance issues, storage and refill at initial consultation). Follow-up at 2 wk, 1 mo, and 3 mo vs usual care (control)No significant difference in frequency of minor (P = .148) or major bleeding events (P = .516) between pharmacist anticoagulation clinic for dabigatran and usual care
      OAC prescribing
      Sandhux223C (PIAAF Rx), study ongoing, Canada

      Sandhu R. Improving stroke prevention in atrial fibrillation through pharmacist prescribing (PIAAFRx). ClinicalTrials.gov Identifier: NCT03126214. 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT03126214. Accessed February 28, 2020.

      Community pharmacy (
      Marcatto et al have one other publication [Ref 48] that uses the same cohort and reports on TTR at weeks 4 and 12 without a breakdown of different warfarin adherence groups
      ), randomized controlled trial
      a370 (estimate)

      b
      not reported.


      c
      not reported.
      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
      available as abstract only.
      , 2021, Canada

      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      Multidisciplinary heart failure clinic (1), general outpatient clinic (1), cohort studya307

      b
      not reported.


      c
      not reported.
      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
      Khalil, 2021, Australia
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      Hospital (1), before-and-after studya65/61

      b72.78 ± * (males), 75.03 ± * (females)/75.30 ± * (males), 74.60 ± * (females)

      c29 (44.6%)/30 (49.1%)
      One-to-one education with pharmacist during admission of 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 < .001)
      Schwab, 2021, USA
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      Hospital (1), cohort studya146/99

      b73.6 ± 14.7/75.2 ± 12.6

      c77 (52.7%)/51 (51.5%)
      Emergency physicians, pharmacists, and electrophysiologists collaborating in shared decision-making model; emergency physician identifies atrial fibrillation patients using ECG, referral to electrophysiologist when atrial fibrillation confirmed, pharmacist determines appropriate OAC, provides medication, arranges post-discharge clinic with electrophysiologist/cardiologist vs usual care (control)Significant increase in proportion of atrial fibrillation patients discharged on OAC (87.8% intervention vs 62.3% control, P ≤ .001)

      Wang
      total cohort of algorithm identified participants, stepped-wedge randomised controlled trial, all participants eventually received intervention
      , 2019, USA
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
      AMS clinics (14), randomized controlled triala1727
      total cohort of algorithm identified participants, stepped-wedge randomised controlled trial, all participants eventually received intervention


      b
      not reported.


      c
      not reported.
      Pharmacist assessment of appropriateness of initiating OAC in atrial fibrillation patients identified with CHA2DS2-VASc score ≥2 and no OAC prescription within 12 mo, 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 = .860)
      Mensah
      available as abstract only.
      , 2019, USA
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      *, cohort studya489

      b
      not reported.


      c
      not reported.
      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 treatment349/489 (71.4%) patients had warfarin initiated or clear documentation to explain reason for the absence of OAC therapy after pharmacist review
      Leef, 2019, USA
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      Veterans Health Administration (1), cohort studya5060

      b69 ± 10

      c96 (1.9%)
      AMS for new atrial fibrillation patients started on NOACs, generally led by pharmacists

      Improvement in correct NOAC dosing when compared with other fee-for-service nonintegrated 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
      Durand
      available as abstract only.
      , 2018, UK
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      General practices (20), before-and-after studya501

      b
      not reported.


      c
      not reported.
      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 < .001

      Brown
      available as abstract only.
      , 2017, UK
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      Outpatient clinics (
      Marcatto et al have one other publication [Ref 48] that uses the same cohort and reports on TTR at weeks 4 and 12 without a breakdown of different warfarin adherence groups
      ), before-and-after study
      a
      not reported.


      b
      not reported.


      c
      not reported.
      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 2 CCGs from 73% (pre-intervention) to 83% (postintervention), and from 72% to 78%
      Virdee, 2017, UK
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      General Practices (15), cross-sectional studya497

      b75.5 ± 11.9

      c206 (41.4%)
      Pharmacist treatment recommendations made to GP for atrial fibrillation patients with CHA2DS2-VASc score ≥1/≥2 (male/female) and no anticoagulant prescription202/497 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
      Dowling, 2016, UK
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      Outpatient clinic (1), cohort studya87

      b76.9 ± *

      c46 (52.9%)
      Pharmacist-led anticoagulant review clinic (weekly, 4-h clinic for 6 mo) 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 2-wk follow-up, 1/87 had VKA discontinued (hemorrhagic risk outweighed benefit), 21/87 (24.1%) remained on VKA
      Larock, 2014, Belgium
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      Hospital (1), cross-sectional studya69

      b74 [45-89]

      c26 (38%)
      Pharmacist assessment of dabigatran and rivaroxaban prescribing using Medication Appropriateness Index tool adapted for NOAC prescribing with recommendations made to physicians34/69 (49%) inappropriate criteria for treatment, 48 pharmacist interventions, 94% accepted by physicians
      Jackson, 2011, Australia
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      Hospital (1), before-and-after studya134/394

      b79 ± */75 ± *

      c84 (63%)/180 (45%)
      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 = .050, significant decrease in aspirin use from 48% to 39%, P = .040 from admission to discharge in intervention group, no significant change in antithrombotic use from admission to discharge in usual care
      Touchette, 2007, USA
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      Hospital (1), before-and-after studya154/98

      b79.7 ± 10.2/77.8 ± 10.1

      c76 (49.4%)/57 (58.2%)
      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 = .580), significant difference in proportion of patients with antithrombotic discharge plan (88.3% intervention vs 73.5% control, P < .01), significantly higher odds of planned or actual warfarin use with intervention (adjusted OR 2.46; 95% CI, 1.63-3.74)
      Bajorek, 2005, Australia
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      Hospital (1), cohort studya218

      b85.2 ± 6.2

      c133(61%)
      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 made78/218 (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 postintervention (at discharge), 59.6% vs 81.2%, P < .001
      Burkiewicz, 2004, USA
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      Outpatient clinics (2), cohorta131/47

      b71.7 ± 11.3/74.7 ± 11.5

      c66 (50.4%)/24 (51.1%)
      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 = .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
      Khalil, 2021, Australia
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      Hospital (1), before-and-after studya65/61

      b72.78 ± * (males), 75.03 ± * (females)/75.30 ± * (males), 74.60 ± * (females)

      c29 (44.6%)/30 (49.1%)
      See Khalil 2021, OAC prescribing

      Significant improvement in patient satisfaction measured using a standard satisfaction survey based on a Likert scale (intervention 68% vs control 25%, P < .001)

      Sun, 2021, China
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      Hospital (1), randomized controlled triala100/99

      b75.9 ± 9.0/75.8 ± 9.1

      c45 (45%)/46 (46.5%)
      Pharmacist implementation of evidence-based pharmaceutical care model. Pharmacists consider patients’ preferences, search and evaluate literature, provide objective suggestions to hospitalized 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 < .01) and cognition scores (22.6 ± 2.2 vs 20.8 ± 3.0, P < .01) measured using a questionnaire designed by the researchers significantly higher in patients in intervention group
      Leblanc
      available as abstract only.
      , 2017, Canada
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      *, cohort studya338

      b
      not reported.


      c
      not reported.
      Pharmacist-delivered education and counseling to atrial fibrillation patients taking NOACs

      Increased patient knowledge (assessed using 5 questions) of atrial fibrillation and NOAC use from 3.7/5 (baseline) to 4.3/5 (4-mo follow-up), increased medication adherence from 93% (baseline) to 98% (4-mo follow-up), P < .001
      Shore, 2015, USA
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      Veterans Health Administration sites (67), mixed-method studya4863

      b
      not reported.
      not reported for the entire cohort of 4,863 participants, only reported for participants taking part in the qualitative aspect of the study.


      c
      not reported.
      not reported for the entire cohort of 4,863 participants, only reported for participants taking part in the qualitative aspect of the study.
      Pharmacist review of dabigatran prescriptions for atrial fibrillation patients, patient education, adverse event and adherence monitoringPharmacist 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)
      Lee, 2013, USA
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      Outpatient clinic (1), before-and-after studya20/48‖

      b78 [72-83]/72 [67-81]

      c0 (0%)/1 (2%)
      See Lee 2013, Health outcomesNo 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 = .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 ischemic attack/thromboembolism and age ≥75 years; CI = confidence interval; ECG = electrocardiogram; GP = general practitioner; HF = heart failure; HR = hazard ratio; INR = international normalized 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 normalized ratio; RR = relative risk; SAFE = safe anticoagulation initiation for atrial fibrillation in the emergency department; TTR = time in therapeutic range; VKA = vitamin K antagonist; WMTAC = warfarin medication therapy adherence clinic.
      Studies reporting on more than one outcome are listed under all relevant outcome headings with reporting of outcome-relevant results only.
      low asterisk not reported.
      Marcatto et al have one other publication [Ref 48] that uses the same cohort and reports on TTR at weeks 4 and 12 without a breakdown of different warfarin adherence groups
      available as abstract only.
      § total cohort of algorithm identified participants, stepped-wedge randomised controlled trial, all participants eventually received intervention
      45/48 participants in control group had atrial fibrillation +/- flutter and 3/48 had atrial flutter only, all participants in intervention group had atrial fibrillation +/- flutter
      not reported for the entire cohort of 4,863 participants, only reported for participants taking part in the qualitative aspect of the study.

      Quality of Warfarin Therapy (TTR)

      Physician–pharmacist collaborations were the most common intervention types in studies reporting on quality of warfarin therapy, using TTR.
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      ,
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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 3 reporting significantly higher TTR in the intervention group compared with controls.
      • An T
      • Kose E
      • Kikkawa A
      • Hayashi H
      Hospital pharmacist intervention improves the quality indicator of warfarin control: a retrospective cohort study.
      ,
      • Kose E
      • An T
      • Kikkawa A
      Assessment of oral anticoagulation control at pharmacist-managed clinics: a retrospective cohort study.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      Two studies found no significant difference in TTR between groups (Table 2).
      • Aidit S
      • Soh YC
      • Yap CS
      • et al.
      Effect of standardized warfarin treatment protocol on anticoagulant effect: comparison of a warfarin medication therapy adherence clinic with usual medical care.
      ,
      • Liang J-B
      • Lao C-K
      • Tian L
      • et al.
      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.
      One study found a significantly higher proportion of participants with TTR ≥60% in the physician–pharmacist atrial fibrillation warfarin clinic compared with those who attended a general clinic (73.7% vs 47.1%, P = .002).
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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 program for atrial fibrillation patients with a TTR <50%. Participants were categorized by warfarin adherence (low: 2 or more missed doses; medium: one missed dose; high: no missed doses).
      • Marcatto L
      • Boer B
      • Sacilotto L
      • et al.
      Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.
      There was a significant difference in basal, 12-week, and 1-year mean TTR within low-, medium-, and high-adherence groups (Table 2).

      Health Outcomes

      Seven studies reported on health outcomes
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      ,
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      ,
      • Kirwan C
      • Ramsden S
      • Kibria A
      • et al.
      LO40: Safe anticoagulation initiation for atrial fibrillation in the emergency department (the SAFE pathway).
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      ,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.
      (Table 2). Only one study that used a before-and-after design was powered to performed adjusted analyses,
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      and found that a pharmacist-led anticoagulant management service 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).
      • Phelps E
      • Delate T
      • Witt DM
      • Shaw PB
      • McCool KH
      • Clark NP
      Effect of increased time in the therapeutic range on atrial fibrillation outcomes within a centralized anticoagulation service.
      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.
      • Jones AE
      • King JB
      • Kim K
      • Witt DM
      The role of clinical pharmacy anticoagulation services in direct oral anticoagulant monitoring.
      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 with patients under the care of cardiologists or primary care providers (gastrointestinal: 6.1% vs 12.4%, P = .038; skin ecchymosis 0.6% vs 4.5%, P = .018).
      • Li X
      • Zuo C
      • Lu W
      • et al.
      Evaluation of remote pharmacist-led outpatient service for geriatric patients on rivaroxaban for nonvalvular atrial fibrillation during the COVID-19 pandemic.
      Other studies reported no association between pharmacist-led interventions and health outcomes.
      • An J
      • Niu F
      • Zheng C
      • et al.
      Warfarin management and outcomes in patients with nonvalvular atrial fibrillation within an integrated health care system.
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Wang N
      • Qiu S
      • Yang Y
      • Zhang C
      • Gu Z-C
      • Qian Y
      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.

      OAC Prescribing

      Most studies explored the impact of pharmacist interventions on the appropriateness of OAC prescribing
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      ,
      • Larock A-S
      • Mullier F
      • Sennesael A-L
      • et al.
      Appropriateness of prescribing dabigatran etexilate and rivaroxaban in patients with nonvalvular atrial fibrillation: a prospective study.
      ,
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      ,

      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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      or OAC prescribing rates (Table 2).
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      ,
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      ,
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      ,
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      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 with 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. Heart Failure 2021 Online Congress [ePoster session]. Available at: https://esc365.escardio.org/presentation/233640.

      Other interventions, including pharmacist-delivered patient education to promote shared decision-making
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      and a pharmacist anticoagulant management program for patients newly initiated on NOACs,
      • Leef GC
      • Perino AC
      • Askari M
      • et al.
      Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation: insights from the Veterans Health Administration.
      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.
      • Dowling T
      • Patel A
      • Oakley K
      • Sheppard M
      Assessing the impact of a targeted pharmacist-led anticoagulant review clinic.
      In 5 studies,
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      ,
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      ,
      • Mensah TM
      • Yates NY
      Pharmacist-led intervention to address patients with atrial fibrillation not receiving anticoagulation.
      ,
      • Virdee MS
      • Stewart D
      Optimizing the use of oral anticoagulant therapy for atrial fibrilation in primary care: a pharmacist-led intervention.
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      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 3 studies explored whether this translated into increased OAC prescribing.
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      ,
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      ,
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
      One randomized controlled trial of 1727 participants found no significant difference in the proportion of OAC prescriptions between intervention and usual care groups (Table 2).
      • Wang SV
      • Rogers JR
      • Jin Y
      • et al.
      Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation.
      In a before-and-after study, higher OAC prescribing rates were reported in 2 clinical commissioning groups,
      • Brown A
      • Byrne R
      • William H
      • Hamedi N
      • Hodgkinson A
      Optimisation of anticoagulation therapy for stroke prevention in atrial fibrillation using a virtual clinic model.
      and in another cohort study, the proportion of atrial fibrillation patients prescribed OAC increased significantly from 62% to 80% (Table 2).
      • Durand L
      • Chahal J
      • Shabana A
      • et al.
      4CPS-018 Specialist pharmacist-led support in primary care to optimise cardiovascular risk management in patients with atrial fibrillation (af-patients).
      Other studies also demonstrated positive effects of other distinct pharmacist-led interventions on increasing OAC prescribing (Table 2).
      • Bajorek BV
      • Krass I
      • Ogle SJ
      • Duguid MJ
      • Shenfield GM
      Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention.
      ,
      • Burkiewicz JS
      Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation.
      ,
      • Jackson SL
      • Peterson GM
      Stroke risk assessment for atrial fibrillation: hospital-based stroke risk assessment and intervention program.
      ,
      • Schwab K
      • Smith R
      • Wager E
      • et al.
      Identification and early anticoagulation in patients with atrial fibrillation in the emergency department.
      ,
      • Touchette DR
      • McGuinness ME
      • Stoner S
      • Shute D
      • Edwards JM
      • Ketchum K
      Improving outpatient warfarin use for hospitalized patients with atrial fibrillation.

      Medication Adherence, Knowledge, and Patient Satisfaction

      Pharmacist-delivered patient education was a core component of 3 studies
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      that reported on patient knowledge
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      and medication adherence (Table 2).
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      ,
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      ,
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      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).
      • Lee P-Y
      • Han SY
      • Miyahara RK
      Adherence and outcomes of patients treated with dabigatran: Pharmacist-managed anticoagulation clinic versus usual care.
      A larger mixed-method study (n = 4863) also found no significant association between pharmacist education and dabigatran adherence (adjusted relative risk 0.94; 95% CI, 0.83-1.06).
      • Shore S
      • Ho PM
      • Lambert-Kerzner A
      • et al.
      Site-level variation in and practices associated with dabigatran adherence.
      In contrast, another educational intervention significantly increased medication adherence from baseline to 4 months and marginally improved patient knowledge about AF and NOAC.
      • Leblanc K
      • Jaffer A
      • Papastergiou J
      • Semchuk B
      NOVEL TECHNOLOGY-ENABLED PHARMACIST AND PATIENT EDUCATION PROGRAM ENHANCES ADHERENCE TO STROKE PREVENTION MEDICATIONS.
      Two studies assessed the effect of pharmacist interventions on patient satisfaction
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.
      and reported significant improvements (Table 2).
      • Sun J
      • Chen GM
      • Huang J
      Effect of evidence-based pharmacy care on satisfaction and cognition in patients with non-valvular atrial fibrillation taking rivaroxaban.
      ,
      • Khalil V
      • Blackley S
      • Subramaniam A
      Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients’ satisfaction—a before and after pilot study.

      "B" Better Symptom Management: Pharmacist Interventions for Symptom Management

      Two studies tested pharmacist interventions for symptom management in atrial fibrillation,
      • Finks SW
      • Rogers KC
      • Manguso AH
      Assessment of sotalol prescribing in a community hospital: opportunities for clinical pharmacist involvement.
      ,
      • Labreck M
      • Robinson A
      • Swinning J
      • et al.
      B-PO02-010 OUTPATIENT SOTALOL LOADING IS SAFE AND EFFECTIVE USING A PHARMACIST-RUN ANTIARRHTHYMIC CLINIC.
      focusing on prescription of sotalol
      • Finks SW
      • Rogers KC
      • Manguso AH
      Assessment of sotalol prescribing in a community hospital: opportunities for clinical pharmacist involvement.
      or the care setting for administration
      • Labreck M
      • Robinson A
      • Swinning J
      • et al.
      B-PO02-010 OUTPATIENT SOTALOL LOADING IS SAFE AND EFFECTIVE USING A PHARMACIST-RUN ANTIARRHTHYMIC CLINIC.
      (Table 3). In one small cohort study (n = 360), pharmacists identified that most (89%) sotalol prescriptions were inappropriate based on patients’ renal function and recommended changes to physicians, but only 38% of recommendations were implemented.
      • Finks SW
      • Rogers KC
      • Manguso AH
      Assessment of sotalol prescribing in a community hospital: opportunities for clinical pharmacist involvement.
      In another study, pharmacists led an anti-arrhythmic outpatient clinic for sotalol loading (oversight from electrophysiologist) to determine feasibility compared with inpatient sotalol loading.
      • Labreck M
      • Robinson A
      • Swinning J
      • et al.
      B-PO02-010 OUTPATIENT SOTALOL LOADING IS SAFE AND EFFECTIVE USING A PHARMACIST-RUN ANTIARRHTHYMIC CLINIC.
      Outpatient sotalol loading was found to be a safe alternative.
      • Labreck M
      • Robinson A
      • Swinning J
      • et al.
      B-PO02-010 OUTPATIENT SOTALOL LOADING IS SAFE AND EFFECTIVE USING A PHARMACIST-RUN ANTIARRHTHYMIC CLINIC.
      Table 3Characteristics of Cohort Studies Implementing Pharmacist-Led Symptom Management Interventions for Atrial Fibrillation
      Author (Study Name), Year, CountryStudy Setting (n)Intervention/Control

      aSample Size

      bAge (Median [IQR], or Mean ± SD)

      cProportion of Females, n (%)
      Description of Intervention and Control (Where Applicable)Main Findings
      Labreck,
      Available as abstract only.
      2021, USA
      • Labreck M
      • Robinson A
      • Swinning J
      • et al.
      B-PO02-010 OUTPATIENT SOTALOL LOADING IS SAFE AND EFFECTIVE USING A PHARMACIST-RUN ANTIARRHTHYMIC CLINIC.
      Antiarrhythmic clinic (1)a12/9

      b
      Not reported.


      c3 (25%)/4 (44.5%)
      Pharmacy-led outpatient clinic using the AliveCor KardiaMobile ECG to deliver sotalol loading (electrophysiologist oversight) vs inpatient sotalol loading (control)Inpatients administered 120 mg twice daily, 88.3% outpatients received this dose (3 received different doses at electrophysiologist discretion (n = 2), or because of prolonged baseline QT interval (n = 1)
      Finks, 2011, USA
      • Finks SW
      • Rogers KC
      • Manguso AH
      Assessment of sotalol prescribing in a community hospital: opportunities for clinical pharmacist involvement.
      Hospital (1)a36

      b75 ± 8.9 dose appropriate or accepted dose adjustment, 78 ± 7.6 partial dose adjustment or no adjustment

      c
      Not reported.
      Pharmacist assessment of sotalol prescribing for atrial fibrillation patients according to renal function, physician prescribing recommendations made when appropriatePharmacist 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 6 mo for patients on appropriate therapy (31% vs 55%, P = .095)
      ECG = electrocardiogram.
      low asterisk Available as abstract only.
      Not reported.

      "ABC": Multifaceted Pharmacist Interventions Covering Two or More Components of the Atrial Fibrillation Better Care Pathway

      Three before-and-after studies explored pharmacist implementation of multifaceted interventions aligned with ≥2 components of the ABC pathway (Table 4).
      • Chahal JK
      • Antoniou S
      • Earley M
      • et al.
      Preventing strokes in people with atrial fibrillation by improving ABC.
      • Gauci M
      • Wirth F
      • Azzopardi LM
      • Serracino-Inglott A
      Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons.
      • Gehi AK
      • Deyo Z
      • Mendys P
      • et al.
      Novel care pathway for patients presenting to the emergency department with atrial fibrillation.
      • Marvanova M
      • Henkel PJ
      A pharmacist-led stroke education and screening program for community-dwelling older adults.
      • Dorian P
      • Bhatia R
      • Lebovic G
      • et al.
      TRANSITIONING EMERGENCY ATRIAL FIBRILLATION MANAGEMENT (TEAM): INTERIM ANALYSIS OF IMPACT ON CLINICAL OUTCOMES.
      • Tran HN
      • Tafreshi J
      • Hernandez EA
      • Pai SM
      • Torres VI
      • Pai RG
      A multidisciplinary atrial fibrillation clinic.
      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.
      • Gauci M
      • Wirth F
      • Azzopardi LM
      • Serracino-Inglott A
      Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons.
      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).
      • Gauci M
      • Wirth F
      • Azzopardi LM
      • Serracino-Inglott A
      Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons.
      In another study, pharmacists used Active Patient Link–Atrial Fibrillation software to identify AF patients potentially eligible for OAC therapy and invited them to attend a general practitioner–pharmacist clinic.
      • Chahal JK
      • Antoniou S
      • Earley M
      • et al.
      Preventing strokes in people with atrial fibrillation by improving ABC.
      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 <5 mmol/L, although this did not translate into a significant increase in statin use. Data on dosage changes to statin therapy are not reported.
      • Chahal JK
      • Antoniou S
      • Earley M
      • et al.
      Preventing strokes in people with atrial fibrillation by improving ABC.
      There was no significant difference in the proportion of patients with uncontrolled blood pressure ≥140/90 mmHg.
      • Chahal JK
      • Antoniou S
      • Earley M
      • et al.
      Preventing strokes in people with atrial fibrillation by improving ABC.
      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.
      • Gehi AK
      • Deyo Z
      • Mendys P
      • et al.
      Novel care pathway for patients presenting to the emergency department with atrial fibrillation.
      Table 4Characteristics of Studies of Pharmacist-Led Educational or Multifaceted Interventions Covering Two or More Components of the ABC Pathway for Atrial Fibrillation
      First Author (Study Name), Year, CountryStudy Setting, (n), Study DesignIntervention/Control

      aSample Size

      bAge (Median [IQR], or Mean ± SD)

      cProportion of Females, n (%)
      Description of Intervention and Control (Where Applicable)Main Findings
      Multifaceted interventions covering 2 or more components of the ABC pathway
      Chahal, 2019, UK
      • Chahal JK
      • Antoniou S
      • Earley M
      • et al.
      Preventing strokes in people with atrial fibrillation by improving ABC.
      General practices (43), before-and-after studya310,972 (2016/17)/320,422 (2017/18)

      b
      Not reported.


      c
      Not reported.
      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, hematologist, GP with specialist interest in cardiology, GP coordinator, 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 < .0001), nonsignificant increase in use of statins (66.8% to 68.1%), but significant increase in serum cholesterol reported as <5 mmol/L (64.2% to 68%, P = .012), no significant difference in proportion of patients with blood pressure ≥140/90 mmHg (2.9% to 3.2%)
      Gauci, 2019, Malta
      • Gauci M
      • Wirth F
      • Azzopardi LM
      • Serracino-Inglott A
      Clinical pharmacist implementation of a medication assessment tool for long-term management of atrial fibrillation in older persons.
      Hospital (1), before-and-after studya150/150

      b82.7 ± 6.4/81.7 ± 7.6

      c106 (70.7%)/96 (64%)

      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 < .001), rate-control (OR 3.92; 95% CI, 1.06-14.54, P = .041), digoxin monitoring (OR 10.40; 95% CI, 3.59-30.10, P < .001), referral of patients on anti-arrhythmic drugs not in sinus rhythm to cardiology (OR 8.00; 95% CI, 1.13-56.79, P = .038)
      Gehi, 2018, USA
      • Gehi AK
      • Deyo Z
      • Mendys P
      • et al.
      Novel care pathway for patients presenting to the emergency department with atrial fibrillation.
      Hospital (1), before-and-after studya98/100

      b68.5 ± 14.2 (all participants)

      c
      Not reported.
      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 d vs postintervention 2.5 ± 4.4 d, P =.560)
      Educational-based interventions
      Dorian, 2020, Canada
      • Dorian P
      • Bhatia R
      • Lebovic G
      • et al.
      TRANSITIONING EMERGENCY ATRIAL FIBRILLATION MANAGEMENT (TEAM): INTERIM ANALYSIS OF IMPACT ON CLINICAL OUTCOMES.
      Hospital EDs (3), cohort studya212

      b65 ±
      Not reported.


      c95 (45%)
      Implementation of nurse practitioner and pharmacist-centered follow-up program (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 mo between patients on AF-QCP follow-up program compared with historic controls

      Marvanova, 2019, USA
      • Marvanova M
      • Henkel PJ
      A pharmacist-led stroke education and screening program for community-dwelling older adults.
      Faith-based institutions (4), before-and-after studya97

      b75.0 ± 13.7

      c69 (71.1%)
      Pharmacist-led education (70-min event; baseline assessment of stroke knowledge, study questionnaire, BP and HR readings, presentation, question-and-answer session, posteducation questionnaire) for community-dwelling adultsParticipants self-reporting atrial fibrillation (n = 6) identified atrial fibrillation management as a modifiable stroke risk factor after pharmacist-led education (none identified it prior to educational session)
      Tran, 2013, USA
      • Tran HN
      • Tafreshi J
      • Hernandez EA
      • Pai SM
      • Torres VI
      • Pai RG
      A multidisciplinary atrial fibrillation clinic.
      Hospital (1), cohort studya71

      b71.7 ± 9.54 clinic patient nonhospitalized with atrial fibrillation, 72 ± 11.8 clinic patient hospitalized with atrial fibrillation

      c22 (31.1%)
      MDT atrial fibrillation clinic led by pharmacists and electrophysiologists to evaluate and implement individualized treatment plans and provide patient education, medication management, and follow-up17/71 (23.9%) clinic patients hospitalized and 2/17 (11.7%) had an ischemic stroke, reduction in hospital admission rate within 1 y when compared with reported national admission rates occurring within 6 mo (23.9% vs 65.8%), study ischemic 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.
      low asterisk Not reported.

      Pharmacist-Led Educational Interventions

      Three studies (one before-and-after
      • Marvanova M
      • Henkel PJ
      A pharmacist-led stroke education and screening program for community-dwelling older adults.
      and 2 cohort studies
      • Dorian P
      • Bhatia R
      • Lebovic G
      • et al.
      TRANSITIONING EMERGENCY ATRIAL FIBRILLATION MANAGEMENT (TEAM): INTERIM ANALYSIS OF IMPACT ON CLINICAL OUTCOMES.
      ,
      • Tran HN
      • Tafreshi J
      • Hernandez EA
      • Pai SM
      • Torres VI
      • Pai RG
      A multidisciplinary atrial fibrillation clinic.
      ) tested pharmacist-delivered education (Table 4). Studies reported on different outcomes and the results were variable.
      • Marvanova M
      • Henkel PJ
      A pharmacist-led stroke education and screening program for community-dwelling older adults.