Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis.

Objective: To undertake a systematic review and meta-analysis examining the impact of polypharmacy on health outcomes in atrial fibrillation (AF). Data sources: PubMed and Embase databases were searched from inception until 31 July 2019. Studies including post hoc analyses of prospective randomised controlled trials or observational design that examined the impact of polypharmacy on clinically significant outcomes in AF including mortality, hospitalisations, stroke, bleeding, falls and quality of life were eligible for inclusion. Results: A total of six studies were identified from the systematic review, with three studies reporting on common outcomes and used for a meta-analysis. The total study population from the three studies was 33 602 and 37.2% were female. Moderate and severe polypharmacy, defined as 5-9 medicines and >9 medicines, was observed in 42.7% and 20.7% of patients respectively, and was associated with a significant increase in all-cause mortality (Hazard ratio [HR] 1.36, 95% CI 1.20 to 1.54, p<0.001; HR 1.84, 95% CI 1.40 to 2.41, p<0.001, respectively), major bleeding (HR 1.32, 95% CI 1.14 to 1.52, p<0.001; HR 1.68, 95% CI 1.35 to 2.09, p<0.001, respectively) and clinically relevant non-major bleeding (HR 1.12, 95% CI 1.03 to 1.22, p<0.01; HR 1.48, 95% CI 1.33 to 1.64, p<0.01, respectively). There was no statistically significant association between polypharmacy and stroke or systemic embolism or intracranial bleeding. Among other examined outcomes, polypharmacy was associated with cardiovascular death, hospitalisation, reduced quality of life and poorer physical function. Conclusions: Polypharmacy is highly prevalent in the AF population and is associated with numerous adverse outcomes. PROSPERO registration number: CRD42018105298.

NursE led Atrial Fibrillation Management: The NEAT Study: A Randomized Controlled Trial.

BACKGROUND: Atrial fibrillation (AF) is a growing epidemic. Current models of care delivery are inadequate in meeting the needs of the population with AF. Furthermore, quality of life is known to be poor in patients with AF and is associated with adverse patient outcomes. OBJECTIVE: The aim of this study was to determine if nurse-led education and cardiovascular risk factor modification, undertaken using the principles of motivational interviewing, facilitated by an electronic decision support tool to ensure the appropriate use of oral anticoagulation (OAC), could improve health-related quality of life (HRQoL), guideline adherence to OAC, and cardiovascular risk factor profiles in individuals with AF. METHODS: This was a multicenter, prospective, randomized controlled feasibility study of 72 individuals with AF. The intervention involved 1 face-to-face nurse-delivered education and risk factor management session with 4 follow-up telephone calls over a 3-month period to monitor progress. The primary outcome measure was HRQoL as assessed by the Short Form-12 survey. RESULTS: A total of 72 participants were randomized, with 36 individuals in each arm completing follow-up. Mean age was 65 ± 11 years and 44% were women. At 3 months follow-up, no significant differences between groups were observed for the physical or mental component summary scores of the Short Form-12, nor any of the subscales. Appropriate use of OAC did not differ between groups at final follow-up. CONCLUSIONS: A brief nurse-delivered educational intervention did not significantly impact on HRQoL or risk factor status in individuals with AF. Further research should focus on interventions of greater intensity to improve outcomes in this population. TRIAL REGISTRATION: ACTRN12615000928516.

Patient-Centered Educational Resources for Atrial Fibrillation.

Education has long been recognized as an important component of chronic condition management. Whereas education has been evaluated in atrial fibrillation (AF) populations as part of multifaceted interventions, it has never been tested as a single entity. The aim of this review is to describe the rationale for and role of education as part of comprehensive AF management. The development and use of educational material as part of the intervention of a randomized controlled trial, the HELP-AF (Home-Based Education and Learning Program in AF) study, will be described. This study was designed to determine the impact of a home-based structured educational program on outcomes in individuals with AF. An educational resource was developed to facilitate delivery of 4 key messages targeted at empowering individuals to self-manage their condition. The key messages focused on strategies for managing future AF episodes, the role of pharmacotherapy in the treatment of AF, the appropriate use of medicines to manage stroke risk and the role of cardiovascular risk factor management in AF. To support structured educational visiting, an educational booklet titled Living Well With Atrial Fibrillation (AF) was developed by a multidisciplinary team and was further refined following input from expert clinicians and patient interviews. Using a structured educational visiting approach, education was delivered by trained clinicians within the patient's home.

Home-Based Education and Learning Program for Atrial Fibrillation: Rationale and Design of the HELP-AF Study.

BACKGROUND: Atrial fibrillation (AF) is a growing global epidemic, with its prevalence expected to significantly rise over coming decades. AF poses a substantial burden on health care systems, largely due to hospitalizations. Home-based clinical characterization has demonstrated improved outcomes in cardiac populations, but its impact on AF remains poorly defined. To test this hypothesis in AF, we developed the Home-Based Education and Learning Program for Patients With Atrial Fibrillation (HELP-AF) study. METHODS: The HELP-AF study is a prospective multicentre randomized controlled trial that will recruit 620 patients presenting to hospital emergency departments (EDs) with symptomatic AF (ANZCTR Registration: ACTRN12611000607976). Patients will be randomized to either the HELP-AF intervention or usual care. The intervention consists of 2 home visits by a nurse or pharmacist trained in the structured educational visiting (SEV) method. Patients in the control group will receive usual discharge follow-up care. RESULTS: The primary endpoints are total unplanned hospital admissions and quality of life. Secondary endpoints include AF symptom severity and burden score; time to first hospital admission; total unplanned days in hospital; total AF-related hospital admissions (including atrial flutter); total cardiac and noncardiac hospital admissions; total AF- or atrial flutter-related; cardiac- and noncardiac-related ED presentations; and all-cause mortality. An economic evaluation will also be performed. Clinical endpoints will be adjudicated by independent blinded assessors. Follow-up will be at 24 months. CONCLUSIONS: This study will assess the efficacy of a home-based structured patient-centred educational intervention in patients with AF.

Inappropriate prescribing in hospitalised Australian elderly as determined by the STOPP criteria.

BACKGROUND: The elderly population is increasing worldwide. Due to age-related physiological changes that affect the pharmacokinetics and pharmacodynamics of drugs, the elderly are predisposed to adverse drug reactions. Prescribing of potentially inappropriate medications (PIMs) has been found to be prevalent among the elderly and PIM use has been associated with hospitalisations and mortality. OBJECTIVES: This study aims to identify the prevalence and nature of pre-admission inappropriate prescribing by using the STOPP (screening tool of older people's prescriptions) criteria amongst a sample of hospitalised elderly inpatients in South Australia. SETTING: Medical, surgical and rehabilitation wards of a public teaching hospital in Adelaide, South Australia. MAIN OUTCOME MEASURE: Pre-admission prevalence of PIM. METHOD: Medication management plans of 100 patients of ≥65 years old were prospectively studied to determine the prevalence of pre-admission PIM use. Sixty-five criteria of STOPP were applied to identify PIMs. RESULTS: The total number of pre-admission medications screened during the study period was 949; the median number of medicines per patient was nine (range 2-28). Overall the STOPP criteria identified 138 PIMs in 60 % of patients. The most frequently encountered PIM was opiates prescribed in patients with recurrent falls (12.3 %), followed by benzodiazepines in fallers (10.1 %) and proton pump inhibitors when prescribed for peptic ulcer disease for long-term at maximum doses (9.4 %). The number of medications were found to have a positive correlation with pre-admission PIM use (r(s) = 0.49, P < 0.01). CONCLUSIONS: Pre-admission PIM use is highly prevalent among the studied population. Strategies to reduce PIM use should be undertaken by physicians and pharmacists. The use of the STOPP criteria in clinical practice to reduce prescriptions of inappropriate medications requires further investigation.

Warfarin and acetaminophen interaction.

A 74-year-old man who was receiving warfarin for atrial fibrillation experienced an abrupt increase in his international normalized ratio (INR) after taking acetaminophen. To investigate this effect, the patient's anticoagulation therapy was stabilized, and he was given acetaminophen 1 g 4 times/day for 3 days. His INR rose from 2.3 before receiving acetaminophen to 6.4 on the day after acetaminophen was discontinued. Warfarin was stopped for 2 days, and the patient's INR returned to 2.0. Warfarin was restarted at the same dosage, and his INR remained within 2.0-3.0 for 6 months. Factor VII activity decreased from 29.4% before acetaminophen therapy to 15.5% when his INR was 6.4, and factor X activity fell from 27.0% to 20.2%. His warfarin plasma concentration was 1.54 microg/ml before acetaminophen compared with 1.34 microg/ml when his INR was 6.4. No significant changes in drug intake, clinical status, diet, or lifestyle were noted. Changes in INR of this magnitude with the addition of another drug during stable anticoagulation therapy suggest a drug interaction. The lack of an increase in warfarin plasma concentration associated with the increased INR suggests a possible pharmacodynamic mechanism for this interaction. Acetaminophen or a metabolite may enhance the effect of oral coumarin anticoagulants by augmenting vitamin K antagonism. Thus, the anticoagulant effect of warfarin may be significantly elevated after only a few days of acetaminophen therapy. Patients receiving warfarin should be counseled to have their INR monitored more frequently when starting acetaminophen at dosages exceeding 2 g/day.

Clinical pharmacy in a South Indian teaching hospital.

OBJECTIVE: To describe how clinical pharmacy is helping to improve medication use at a South Indian teaching hospital by addressing medication use problems, which are commonly encountered in India. SUMMARY: Clinical pharmacy is practiced in many countries and makes a significant contribution to improved drug therapy and patient care. India is a country with significant problems with medication use, but until recently Indian pharmacists have not been educated for a patient-care role. Postgraduate pharmacy practice programs have been established at 2 pharmacy colleges in South India as a result of a joint Indo-Australian program of cooperation. At a teaching hospital associated with the colleges, clinical pharmacy services such as drug information, medication counseling, drug therapy review, adverse drug reaction reporting, and the preparation of antibiotic guidelines are assisting clinicians to improve drug therapy and patient care. Seven hundred twenty-seven requests for drug information were received from July 1997 to February 2001, and 543 suspected adverse drug reactions were evaluated from November 1997 to February 2001. The most common drug classes causing adverse drug reactions were antibiotics, nonsteroidal antiinflammatory drugs, and antitubercular agents. Physician opinion and service utilization have also been surveyed: 82% of respondents had sought drug information from the Clinical Pharmacy Department and 71% of respondents had sought advice on individual patient management. The success of this program is raising awareness of clinical pharmacy among pharmacy educators elsewhere in India and has led to the introduction of clinical pharmacy services at other Indian hospitals.