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Pharmacist Management of Atrial Fibrillation
Pharmacy Perspectives: Key Takeaways From the 2023 Atrial Fibrillation Guideline Updates

Released: June 13, 2024

Expiration: June 12, 2025

Craig I. Coleman
Craig I. Coleman, PharmD, FASHP, FACC
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Key Takeaways
  • The updated atrial fibrillation (AF) guidelines from the ACC/AHA/ACCP/HRS recommend utilizing shared decision-making strategies in all points of care, including pharmacy.
  • Pharmacists play a critical role in monitoring at-risk patient populations with AF.
  • Join our live, virtual “Ask the Expert” webinar session on July 25, 2024 to have your questions on updates in AF management answered by expert cardiology faculty.

There are several key takeaways for pharmacists from the American College of Cardiology, American Heart Association, American College of Clinical Pharmacy, and Heart Rhythm Society updated atrial fibrillation (AF) guidelines. One thing the guidelines really make clear is the importance of implementing shared decision-making (SDM) with patients, and as pharmacists are among the most accessible healthcare professionals (HCPs), there is real opportunity for them to make a difference in the care of these patients. Further, the guidelines provide some great tools and resources for SDM in terms of screening and managing AF that I would highly recommend all pharmacists consider using.

SDM to Improve Outcomes
Employing a SDM model allows HCPs to partner with patients on designing an individualized plan and empowering patients in ownership of their healthcare. Given that pharmacists are highly accessible HCPs, we can readily employ SDM when we interact with patients. For example, a patient picking up a new prescription in the community setting presents an opportunity to use SDM. Regardless of your practice setting, pharmacists should review therapy choice, assess dosing, and discuss adherence with patients. We must ensure proper adherence to therapy, which means evaluating refill records and addressing any potential barriers. Further, SDM gives us the opportunity to discuss the risks and benefits of prescribed medications with patients. If we identify gaps in adherence or persistence with prescribed anticoagulants, for example, we can use SDM tools to improve patient adherence and outcomes.

Community and ambulatory care pharmacists can help to ensure the appropriate therapy is chosen for each patient. The guidelines recommend direct oral anticoagulants (DOACs) in patients with AF at risk of cardioembolic stroke (>2% per year) with some exceptions (eg, those with mitral stenosis or mechanical heart valves). Within this therapy choice, pharmacists can advocate for appropriate dosing for all patients. Often, DOACs are intentionally underdosed among frail, older patients because HCPs are concerned about their bleeding risk. However, off-label dose adjustments are not supported by evidence and put patients at a higher risk of stroke.

The updated guidelines also recommend HCPs monitor for drug–drug interactions, which is a key role for pharmacists as the drug experts on the team. The guidelines’ SDM tools offer a validated approach to discussing the risks and benefits of anticoagulation therapy to prevent strokes. Though I am always hesitant to make suggestions that would increase pharmacists’ workload, especially in the community setting, SDM can improve outcomes and is certainly something we should add to our pharmacy practice.

Wearable Technologies to Manage AF
Another key role for pharmacists in AF management is educating patients and assessing the data from their wearable devices. These technologies not only measure pulse but can also pick up AF. Pharmacists can further discuss and educate patients on their risk factors and data, including any related consequences, and refer them to the appropriate specialists (ie, cardiology) for diagnostic evaluation and management when appropriate.

Monitoring of At-Risk Populations
The guideline updates have now placed a large emphasis on AF classification, in particular, pre-AF, which is defined as the presence of modifiable and nonmodifiable risk factors for AF. Pharmacists should consistently monitor patients for these and take steps to help patients address modifiable risk factors. Strategies include educating on weight loss, exercise, alcohol and tobacco cessation, screening for and treating sleep apnea, and optimizing blood pressure and glucose control. Many risk factors for AF overlap with risk of bleeding, including improving blood pressure and modifying alcohol intake. In addition, pharmacists can evaluate medications to reduce the risk of bleeding (eg, discontinuing nonsteroidal anti-inflammatory drugs, aspirin, and agents that will enhance anticoagulant effects) and falls.

As mentioned, the correct DOAC dosing is critical, and pharmacists should closely monitor patients with renal insufficiency or chronic kidney disease to ensure the appropriate dose is being used. We need to ensure patients receive the specific dosing indicated by the package label. Finally, with HCPs’ fear of bleeding and falls and the common underdosing of DOACs, it is helpful for pharmacists to be aware of these issues and to be prepared to discuss with patients about their AF and risk of stroke.

Inpatient pharmacists should know when anticoagulants are started and really focus on special populations. For example, for a long time, there was a hesitancy with using DOACs in patients with obesity due to concerns for efficacy. We now have data to show that DOACs are both safe and effective in patients with obesity and are recommended over warfarin even for patients with Class III obesity (BMI >40 kg/m2) except in the case of bariatric surgery, which should alleviate pharmacists’ fear of recommending DOACs in this population.

In addition, inpatient pharmacists will need to monitor for and help manage life-threatening bleeds. Inpatient pharmacists should recommend using the preferred reversal agents whenever possible, for example, andexanet alfa for rivaroxaban, apixaban, and edoxaban or prothrombin complex concentrate and fresh frozen plasma for warfarin. When guidelines or evidence support specific reversal agents, we should do everything we can as pharmacists to ensure our patients receive those agents when needed.

Your Thoughts?
As a pharmacist, what are some barriers to optimizing anticoagulation in patients with AF in your practice? You can get involved in the discussion by answering the poll or posting a comment below.

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As a pharmacist, what are some barriers to optimizing anticoagulation in patients with AF in your practice? [select all that apply] 

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