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The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional–led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single–time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Contains fulltext : 291332.pdf (Publisher’s version ) (Open Access) INTRODUCTION: The 2019 European Society of Cardiology and European Atherosclerosis Society (2019 ESC/EAS) guidelines stress the importance of managing low-density lipoprotein cholesterol (LDL-C) after myocardial infarction (MI) to reduce the risk of cardiovascular events. Information on guideline implementation is limited. The aim of this survey was to describe current clinical practice regarding LDL-C management in the first year post-MI across Europe, improving understanding of the role of ESC/EAS guidelines on clinical practice. METHODS: A qualitative web-based cross-sectional physician survey about the patient pathway and LDL-C management post-MI was conducted in 360 physicians from France, Italy, Germany, The Netherlands, Spain, and the UK (n = 60/country) between December 2019 and June 2020. Secondary and primary care physicians (SCPs/PCPs) described their experiences treating patients post-MI over the preceding 2 months. RESULTS: Physicians reported that on average 90.7% of patients not prescribed lipid-lowering therapy (LLT) before an MI initiated LLT as inpatients; for patients already taking LLT, treatment was intensified for 64.7% of inpatients post-MI. SCPs reported prescribing higher-intensity statins and/or ezetimibe for between 72.3% (Italy) and 88.6% (UK) of patients post-MI. More than 80.0% of SCPs and 51.2% of PCPs stated that they would initiate a change in LLT immediately if patients did not achieve their LDL-C treatment goal by 12 weeks post-MI; 82.0% of SCPs and 55.1% of PCPs reported referring to 2019 ESC/EAS guidelines for management of patients post-MI. Barriers to initiating PCSK9 inhibitors (PCSK9is) included prior prescription of a maximally tolerated dose of statin (49.4%) and/or ezetimibe (38.9%), requirement to reach threshold LDL-C levels (44.9%), and pre-authorization requirements (30.4%). CONCLUSION: Differences in clinical practice post-MI were reported across the countries surveyed, including divergence between 2019 ESC/EAS and local guidelines. Increased use of innovative medicines to achieve LDL-C goals should reduce risk of subsequent cardiovascular events in very high-risk patients post-MI. 01 januari 2023

Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care.This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients.Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in 48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months.The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for48 hours (48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses.Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.

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Background: Contrast-induced nephropathy (CIN), an acute kidney injury resulting from the administration of intravascular iodinated contrast media, is a significant cause of morbidity/mortality following coronary angiographic procedures in high-risk patients. Despite preventative measures intended to mitigate the risk of CIN, there remains a need for novel effective treatments. Evidence suggests that delivery of nitric oxide (NO) through chemical reduction of inorganic nitrate to NO may offer a novel therapeutic strategy to reduce CIN and thus preserve long term renal function. Design: The NITRATE-CIN trial is a single-center, randomized, double-blind placebo-controlled trial, which plans to recruit 640 patients presenting with acute coronary syndromes (ACS) who are at risk of CIN. Patients will be randomized to either inorganic nitrate therapy (capsules containing 12 mmol KNO3) or placebo capsules containing potassium chloride (KCl) daily for 5 days. The primary endpoint is development of CIN using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A key secondary endpoint is renal function over a 3-month follow-up period. Additional secondary endpoints include serum renal biomarkers (e.g. neutrophil gelatinase-associated lipocalin) at 6 h, 48 h and 3 months following administration of contrast. Cost-effectiveness of inorganic nitrate therapy will also be evaluated. Summary: This study is designed to investigate the hypothesis that inorganic nitrate treatment decreases the rate of CIN as part of semi-emergent coronary angiography for ACS. Inorganic nitrate is a simple and easy to administer intervention that may prove useful in prevention of CIN in at-risk patients undergoing coronary angiographic procedures.

Purdue University College of Pharmacy offers an international advanced pharmacy practice experience (APPE) in London, England, where student pharmacists have the opportunity to work with pharmacy specialists at St. Bartholomew’s Hospital. The COVID-19 pandemic has significantly impacted travel across the world and created the need to transition this experience from in-person to virtual. Virtual interaction with international preceptors and revised research and clinical activities can provide students with a valuable learning experience.

"Background: This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. Methods: It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. Results: Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self‐management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. Conclusion: On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care." info:eu-repo/semantics/publishedVersion

ObjectiveThere has been limited systematic evaluation of outcomes and drivers of inappropriate non-vitamin K antagonist oral anticoagulants (NOACs) dosing among patients with atrial fibrillation (AF). This review identified and systematically evaluated literature on clinical and economic outcomes of inappropriate NOAC dosing and associated patient characteristics.MethodsMEDLINE, Embase, Cochrane Library, International Pharmaceutical Abstracts, Econlit, PubMed and NHS EEDs databases were searched for English language observational studies from all geographies published between 2008 and 2020, examining outcomes of, or factors associated with, inappropriate NOAC dosing in adult patients with AF.ResultsOne hundred and six studies were included in the analysis. Meta-analysis showed that compared with recommended NOAC dosing, off-label underdosing was associated with a null effect on stroke outcomes (ischaemic stroke and stroke/transient ischaemic attack (TIA), stroke/systemic embolism (SE) and stroke/SE/TIA). Meta-analysis of 15 studies examining clinical outcomes of inappropriate NOAC dosing found a null effect of underdosing on bleeding outcomes (major bleeding HR=1.04, 95% CI 0.90 to 1.19; p=0.625) but an increased risk of all-cause mortality (HR=1.28, 95% CI 1.10 to 1.49; p=0.006). Overdosing was associated with an increased risk of major bleeding (HR=1.41, 95% CI 1.07 to 1.85; p=0.013). No studies were found examining economic outcomes of inappropriate NOAC dosing. Narrative synthesis of 12 studies examining drivers of inappropriate NOAC dosing found that increased age, history of minor bleeds, hypertension, congestive heart failure and low creatine clearance (CrCl) were associated with an increased risk of underdosing. There was insufficient evidence to assess drivers of overdosing.ConclusionsOur analysis suggests that off-label underdosing of NOACs does not reduce bleeding outcomes. Patients prescribed off-label NOAC doses are at an increased risk of all-cause mortality. These data underscore the importance of prescriber adherence to NOAC dosing guidelines to achieve optimal clinical outcomes for patients with AF.PROSPERO registration numberCRD42020219844.

SARS-CoV2 is dramatically impacting the global population. Worldwide, pharmacists are changing their roles and being increasingly recognized for their role as essential service providers. This commentary provides some examples collected from Asia, Europe, the Americas and Africa, ranging from essential services to meet human rights basic needs, extended generalist services developed to ensure continuity of care and supply of essential medicines to the development of differentiated extended responsibilities in emergency care. All examples were collected using a network of pharmacists from 27 countries, representing various areas of pharmacy practice, education and research and outreaching to include patient advocates. Selected services illustrate good practice, capability to adapt and contribution to universal health coverage. Above all, it demonstrates the commitment and innovation of the pharmaceutical workforce in the fight against COVID-19.

The lack of antidotes for activated factor X‐inhibitor direct oral anticoagulants (DOACs) means that management of bleeding consists largely of existing supportive therapies. This study aimed to: (i) examine the relative frequency of DOAC‐related major bleeding in relation to DOAC prescriptions over the study period; (ii) describe the presentation and haematological management of DOAC‐related major bleeding; and (iii) evaluate the association between the use of prothrombin‐complex‐concentrate (PCC) and in‐hospital mortality. Over a 3‐year period, 32 UK hospitals submitted data on haematological management of DOAC‐related bleeding. Data consisted of 421 episodes (67%, 21%, 11% and 1% on rivaroxaban, apixaban, dabigatran and edoxaban respectively) of major bleeding on DOACs. The proportion of major bleeds on DOACs and DOAC prescriptions increased throughout the study. Overall, 44% and 37% of patients presented with gastrointestinal bleeding and intracranial haemorrhage (ICH) respectively. Drug concentrations were seldom measured. Compared to no PCC, there was a borderline evidence that receiving low dose PCC (≤25 iu/kg) was associated with better outcomes in terms of mortality (sub‐distribution hazard ratio: 0·15; 95% confidence interval: 0·02–1·19; P = 0·07): but this was not the case for higher doses. DOAC concentrations are seldom measured. There was no evidence of benefit for PCC on in‐hospital mortality.

Introduction COVID-19 has disrupted pathways of care for over 12 months. Primary care has transformed dramatically with much care being provided remotely. The COVID surges and vaccination programme have reduced capacity further. People with conditions such as hypertension, cardiovascular disease and diabetes depend on regular review and treatment optimisation to keep them well. There is a high risk that continued disruption to proactive care will drive an increase in exacerbations and complications. It is likely this will drive further waves of demand for urgent care over the coming months in primary care, in emergency departments and in hospital admissions. Methods The team of GPs & pharmacists at UCLPartners, with patient and public support, developed proactive care frameworks for six conditions including atrial fibrillation, hypertension, high cholesterol and type 2 diabetes mellitus. The frameworks focus on the 'how to' of delivering care in the new world of primary care post COVID-19. They are built on 4 principles: virtual where appropriate, use of the wider workforce, step change in self-management, and use of digital resources. For each condition, the frameworks include: risk stratification tools;pathways that support remote care and deploy staff such as healthcare assistants and social prescribers to systematically support education, self-management and lifestyle change;scripts, protocols and training to guide these staff in consultations;digital tools;and resources to support treatment optimisation. The frameworks include clinical and project management support for local pathway adaptation and implementation. Results The frameworks have gained wide traction in primary care across England. There have been over 2,700 downloads of the search/stratification tools with evidence of implementation in several regions. In the UCLP geography, North East London and North Central London have adopted the frameworks for roll out across 475 GP practices and 2.8 million people. NHSEngland has now adopted the Frameworks as a key part of the NHS@Home programme with plans to support at scale national roll out. Evaluation is being commissioned. Conclusions The UCLPartners Proactive Care Frameworks provide systematic, evidence-based support to restore services post COVID: stratifying so that higher risk patients can be prioritised and workload managed;maximising remote care;optimising personalisation and support for self-care. By using a population health management approach together with comprehensive resources to support clinical management in real world primary care, the frameworks provide a platform not just to restore services but to optimise treatment and outcomes in the high-risk conditions for CVD. The widespread national traction the frameworks are gaining suggests that despite the pandemic, this brings an opportunity to deliver the NHS Long Term Plan ambitions for CVD prevention and prevent 150,000 heart attacks, strokes and cases of dementia.

AimsTo examine the relationship between self-reported level of workplace support (WS) and various mental health outcomes in HCPs and non-HCPs at different time-points during the COVID-19 pandemic, and to examine whether improved WS is associated with improved mental health outcomes over time. Lastly, to identify what support healthcare professionals (HCPs) perceive to be most helpful.MethodsCohort survey study at baseline (July-September 2020) and follow-up (approximately four months later).SettingHCPs working in primary or secondary care, from UK and other countries, and non-HCP controls from primarily London-based universities.Participants1574 HCPs and 147 non-HCPs (academic and research staff at London-based universities). The inclusion criteria for the study were: 1) aged 18 or older, 2) electronic consent given, and 3) identified as HCP or non-healthcare academic staff or self-declared non-HCPs.Main outcome measuresPresence of generalized anxiety disorder (assessed using the GAD-7), clinical insomnia (ISI), major depressive disorder (PHQ-9), well-being (SWEMWBS), and burnout (emotional exhaustion and depersonalization; EEDP2Q). Qualitative data exploring what support HCPs perceive as most useful was gathered using free-text inputs.ResultsAt baseline and follow-up, consistently, compared to those who felt unsupported, those who felt supported had significantly reduced risk (odds) of generalized anxiety disorder (baseline: 59% [95% CI of OR, 0.29 to 0.57], follow-up: 41% [0.38 to 0.92]), clinical insomnia (51% [0.34 to 0.69], 66% [0.20 to 0.55]), major depressive disorder (58% [0.31 to 0.58], 54% [0.31 to 0.74]), emotional exhaustion (65% [0.26 to 0.46], 61% [0.27 to 0.56]) and depersonalization (58% [0.28 to 0.61], 68% [0.21 to 0.50]).At follow-up, self-reported improved WS (vs. baseline) was associated with significantly improved GAD-7 (adjusted difference. −1.73 [-2.54 to −0.91]), ISI (-0.96 [-1.88 to −0.04]), PHQ−9 (-1.32 [-2.16 to −0.49]), SWEMWBS (0.97 [0.37 to 1.57]) and EEDP2Q (burnout) (-1.30 [-1.82 to −0.79]) scores, independent of baseline level of support.Five themes were identified constituting WS: ‘managerial support’ was the largest sub-theme.ConclusionA consistent association was observed between level of WS and the mental health of HCPs and non-HCPs. Improved WS was associated with improved mental health scores over a four-month period during the pandemic.

Countries strive to find suitable solutions to offer health services to their populations. Pharmacist-led services are a possible solution to supplement the care offer with a clear advantage of proximity, with demonstrated expertise in medication use. This paper aims to audit the scope of antithrombotic care services available; and to describe the arrangements adopted for meeting the needs of the population. A multi-stage project involved the development of the list of services, generated during a face-to-face expert meeting; the definition of each service by literature search; and their clustering into three main groups (general, specific and support); resulting in an online audit of each service's availability, the settings where the service was available and the possible providers. The audit was distributed to a taskforce devoted to antithrombotic care representing 22 countries, with response obtained for all. Most reported general services were Transfer of care and Comprehensive Medication Review. Among specific services, Point-of-care testing for INR and renal function and Patient Education on antithrombotic care (antiplatelets and anticoagulants) were the most frequent. Interprofessional Education as a support service was very common, but the use of the Choosing Wisely initiative to inform evidence-based decisions was still limited. There was wide diversity found in arrangements for the provision of services to support patients taking antithrombotic medication, albeit specific services were reported in over half the surveyed countries.

Introduction Approximately 20% of patients suffer from major adverse cardiovascular events (MACE), within 5 years of stopping dual antiplatelet therapy (DAPT), following an acute coronary syndrome (ACS) event. As such, prolonged DAPT, with aspirin and ticagrelor, has shown significant reductions in MACE, offset by an increased risk of major bleeding. The DAPT score offers a means to predict those who would derive benefit from prolonged therapy. We sought to evaluate applicability of the DAPT score to our population in a tertiary heart attack unit. Method Anonymised data was reviewed as part of a larger quality improvement initiative associated with management of ACS. ACS was defined according to standard international criteria. DAPT scores were calculated and compared against our cohort of patients who would have met criteria for prolonged DAPT as per PEGASUS. Patients were excluded if they were at high risk of bleeding, as assessed using CRUSADE scores ≥ 41, or required anticoagulation. Results Between September to December 2019, 304 patients presented with ACS, of which 89 patients were excluded due to high bleeding risk (56) and concomitant anticoagulation (33). 38 patients were excluded as there was insufficient data to calculate DAPT scores. Of the remaining 177 patients, 55% met PEGASUS criteria for prolonged DAPT, largely driven by multivessel disease (66%). When undertaking the DAPT score, this suggested benefit from prolonged DAPT in 53% of patients meeting PEGASUS criteria. Conclusion Applying the DAPT score identified just upward of 50% of patients that may benefit from prolonged DAPT. Patients over the age of 65 is a key inclusion criterion in PEGASUS that derived benefit from prolonged therapy; however, is also a risk factor for major bleeding and as such, a negative predictor factor in the DAPT score. This may contribute to the 50% of patients who met criteria for prolonged DAPT as per PEGASUS but would not warrant prolonged DAPT when applying the DAPT score. This review suggests that risk stratification through use of a suitable risk tool (DAPT score) may help to widen the risk benefit of prolonged DAPT by excluding those likely to bleed while ensuring patients at highest ischemic risk are appropriately targeted. Conflict of Interest None

Aim Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI. Methods and results This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388). Conclusion These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.

Background: Atrial fibrillation (AF) is a cardiac arrhythmia responsible for one third of ischemic strokes. Early detection of AF plays an important role in preventing embolic stroke. Objectives: This study aimed to test the feasibility of an awareness event including opportunistic screening for atrial fibrillation; and to test the reliability of the innovative portable electrocardiogram (ECG) device used. Methods: An awareness campaign was held during two weeks, where individuals consenting to participate in a pharmacist-led detection event, received a manual pulse check, were clinically evaluated and subject to a single-lead electrocardiogram using AliveCor Kardia® mobile. ECGs highlighted as possible AF were confirmed by the cardiologist and those signalled with abnormalities in cardiac rhythm were referred to their physician. Data were collected in a password protected application and analyzed using SPSS, v.24. The Kardia® mobile's sensitivity and specificity was tested against the standard 12-lead ECG. Results: The awareness event involved 223 individuals, among which 205 were screened. Mean age was 66 years (SD = 15) and hypertension was the most frequently reported (n = 107; 52.2%). Mean CHAD2DS2- VASc score was 3 (SD = 1.8). Cardiac irregularities were identified in 45 individuals, 14 confirmed to be new cases of AF (6.8%) by the cardiologist. The sensitivity and specificity were 90.9% and 97.4%. Conclusion: Data suggests this device to be potentially useful for opportunistic early detection of AF, provided interprofessional collaboration is guaranteed so that suspect cases are adequately managed and in a timely way. Fourteen new cases of AF were identified in the population studied, suggesting the pharmacist working in a multiprofessional context, may have had an important role in preventing potential ischemic-related strokes with this initiative. All healthcare professionals involved in the patient pathway should play a more active role in contributing to better health outcomes, particularly within primary care. info:eu-repo/semantics/publishedVersion

Background The prevalence of coronary heart disease amongst South Asian population in the UK is higher compared to the general population. Objective This study sought to investigate beliefs and experiences of South Asian patients regarding coronary heart disease and medication taking behaviour. Setting A London Heart Attack Centre. Methods This mixed method study is part of an original pilot randomised study on 71 patients involving a pharmacy-led intervention to improve medication adherence in coronary heart disease patients. South Asian patients from the randomised study took part in qualitative semi-structured telephone interviews. Both South Asian and non-South Asian patients completed the questionnaire about adherence and beliefs regarding medicines using Morisky Scale and the Belief About Medicines Questionnaire-Specific at 2 weeks, 3 and 6 months. Outcome Patients’ beliefs about coronary heart disease and medication adherence. Results Seventeen South Asian patients and 54 non-South Asian patients took part. Qualitative data from 14 South Asian patients showed that while some attributed coronary heart disease to genetic, family history for their illness, others attributed it to their dietary patterns and ‘god’s will’ and that little could be done to prevent further episodes of coronary heart disease. On the Belief About Medicines Questionnaire-Specific in South Asian patients, beliefs about necessity of medicines outweighed concerns. South Asian patients (n = 17) showed a similar pattern of adherence compared to non-Asian patients (n = 54). Adherence decreased with time in both populations, adherence measured by Morisky Scale. Conclusion South Asian patients in this study often attributed coronary heart disease to additional causes besides the known risk factors. Future studies on their understanding of the importance of cultural context in their attitudes to prevention and lived experience of the disease is warranted. Electronic supplementary material The online version of this article (10.1007/s11096-018-0760-3) contains supplementary material, which is available to authorized users.

Objectives: In the follow-up of patients in a trial of intracoronary sodium nitrite given during primary percutaneous coronary intervention (PCI) after acute myocardial infarction (AMI), we found a reduction in the incidence of major adverse cardiac events (MACEs). Specifically, MACE rates were 5.2% versus 25.0% with placebo at 3 years ( P = .013). Such MACE reductions should also be associated with economic benefit. Thus, we assessed the cost utility of sodium nitrite therapy versus standard primary PCI only. Methods and Results: We developed a model to simulate costs and quality-adjusted life years (QALYs) over the first 36 months after ST-Segment Elevation Myocardial Infarction (STEMI). Decision tree analysis was used to assess different potential cardiovascular outcomes after STEMI for patients in both treatment groups. Model inputs were derived from the NITRITE-AMI study. Cost of comparative treatments and follow-up in relation to cardiovascular events was calculated from the United Kingdom National Health Service perspective. Higher procedural costs for nitrite treatment were offset by lower costs for repeat revascularization, myocardial infarction, and hospitalization for heart failure compared to primary PCI plus placebo. Nitrite treatment was associated with higher utility values (0.91 ± 0.19 vs 0.82 ± 0.30, P = .041). The calculated incremental cost-effectiveness ratio of £2177 per QALY indicates a cost-effective strategy. Furthermore, positive results were maintained when input parameters varied, indicating the robustness of our model. In fact, based on the difference in utility values, the cost of nitrite could increase by 4-fold (£2006 per vial) and remain cost-effective. Conclusion: This first analysis of sodium nitrite as a cardioprotective treatment demonstrates cost-effectiveness. Although more comparative analysis and assessment of longer follow-up times are required, our data indicate the considerable potential of nitrite-mediated cardioprotection.

BackgroundDespite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England.AimTo identify reasons for variation between English CCGs in anticoagulation for AF.Design and settingA 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework.MethodMultiple regression and Pearson’s correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality.ResultsThe proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA2DS2VASc rather than CHADS2 score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = −0.81; 95% confidence intervals = −0.92 to −0.71; PConclusionAnticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA2DS2VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.

Background: Guidelines on the management of orally anticoagulated patients are continuously evolving, leading to an increased need for pharmacists to be fully integrated in care provision. Objective: To identify self-reported gaps in confidence among practicing pharmacists in the area of anticoagulation. Setting Pharmacists in different work settings in different countries. Method: Cross-sectional international survey from October 2015 till November 2016 among pharmacists working in different settings to assess their level of confidence when delivering anticoagulants as well as to identify possible educational needs regarding this medication class. Validation of the survey was ensured. Results: Responses from 4212 pharmacists originating from 18 countries were obtained. Pharmacists’ level of confidence was significantly higher (p < 0.001) when advising patients on vitamin K antagonists (VKAs) versus non-vitamin K antagonists (NOACs). In general, hospital pharmacists displayed higher confidence levels compared to community pharmacists when advising patients on anticoagulation (p < 0.001). Two distinct patterns of confidence levels emerged relating to basic and advanced pharmaceutical care. Confidence levels when providing advanced pharmaceutical care were significantly higher for Oceania and lower for South America (p < 0.005). Conclusions: Pharmacists felt more confident in supporting patients receiving VKAs compared to the more recently introduced NOACs. With the increasing use of NOACs and the risks pertaining to anticoagulation therapy, it is essential to invest in education for pharmacists to address their knowledge gaps enabling them to confidently support patients receiving oral anticoagulants. The project was funded by the Davie-Ratnoff-Macfarlane (DRM) foundation. info:eu-repo/semantics/publishedVersion

Aims To use the Global Registry of Acute Coronary Events (GRACE) and Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) scores to risk stratify antiplatelet treatment post-acute coronary syndrome (ACS). Methods and results This was a prospective registry of 3374 patients undergoing percutaneous coronary intervention for ACS between 2013 and 2015 at a UK cardiac centre. Patients with either low GRACE or high CRUSADE risk scores were stratified either to clopidogrel therapy or ticagrelor was used. The primary endpoint was major adverse cardiac events (MACE) defined as death, non-fatal myocardial infarction, stroke, or target vessel revascularization with bleeding rates as a secondary outcome, assessed at a median follow-up of 1.8 years (interquartile range 0.8-3.4 years). A total of 1723 (51.1%) patients were risk stratified to either clopidogrel (n = 520) or ticagrelor treatment (n = 1203), with the remaining 1651 not risk scored and treated with clopidogrel therapy. Patients in the risk score stratified group were older than the control group otherwise the groups were similar. Over the follow-up period, a significant reduction in MACE rates between the patients' risk score stratified and control (clopidogrel therapy) (13.7% vs. 19.7%, P

Atrial fibrillation (AF) accounts for up to one third of strokes, one of the lead mortality causes worldwide. The European Society of Cardiology guidelines recommend opportunistic screening as a means to increase the odds of early detection and institution of appropriate treatment according to risk factors identified. However, in most countries there are various barriers to effective uptake of screening, including low awareness. The Atrial Fibrillation Association is a patient association engaged with raising awareness of AF. Establishing a partnership with the International Pharmacists for Anticoagulation Care Taskforce, we set as goals to test a model for raising awareness of AF involving pharmacists globally; and to identify barriers and enablers to its implementation. A cross-sectional study was conducted during the Arrhythmia Alliance World Heart Rhythm Week. Pharmacists from 10 countries invited individuals (≥ 40 years; without anticoagulation therapy of AF) to participate in the awareness campaign. Participants agreeing were engaged in the early detection of AF (EDAF) using pulse palpation. Individuals with rhythm discrepancies were referred and prospectively assessed to have information on the proportion of confirmed diagnosis, leading to estimate the detection rate. Interviews with country coordinators explored barriers and enablers to implementation. The study involved 4193 participants in the awareness campaign and 2762 in the EDAF event (mean age 65.3 ± 13.0), of whom 46.2% individuals were asymptomatic, recruited across 120 sites. Most common CHA2DS2-VASc risk factor was hypertension. Among 161 patients referred to physician, feedback was obtained for 32 cases, of whom 12 new arrhythmia diagnoses were confirmed (5 for AF, 2 for atrial flutter), all among elders (≥ 65 years). Qualitative evaluation suggested a local champion to enable pharmacists’ success; technology enhanced engagement amongst patients and increased pharmacists’ confidence in referring to physicians; interprofessional relationship was crucial in success. This study suggests pharmacists can contribute to greater outreach of awareness campaigns. Effective communication pathways for inter-professional collaboration were suggested enablers to gain full benefits of EDAF.

Atrial Fibrillation (AF) is a common cardiac/heart disease that increases a person’s risk of death, making early identification significant in overall disease management. Throughout my time in pharmacy school, I [Brian] have developed an interest in cardiology and research. During my last year of pharmacy school, I spent eight weeks at St. Bartholomew’s Hospital, in London, England, one of the largest cardiac centers within Europe, on an experiential training experience. While there, I had the opportunity to study specifics about many cardiac illnesses, with a focus on atrial fibrillation, and provide education to patients living with this disease. In addition to working with patients and expanding my knowledge, I participated in an exciting research project that allowed me to connect with the general population and share my knowledge about arrhythmias, which is something I’d like to continue to do after graduation. Our research project aimed to identify the role pharmacists could play in early detection of arrhythmias, particularly atrial fibrillation, and increase the population’s awareness and understanding of this illness. For our project, a pharmacist or student pharmacist was partnered with nursing staff to provide opportunities for heart rate and rhythm monitoring as well as individualized education to help ensure interested patients were more aware of the risks, signs, and symptoms of atrial fibrillation going forward. When patients met with the team, they had their heart rhythms assessed using the AliveCor Kardia ™ single-lead electrocardiogram (ECG) system. This new technology allows patients to place their fingers on a small strip that is able to accurately assess a person’s heart rate and rhythm to identify any irregularities/arrhythmias. Participants were also provided education about atrial fibrillation in hopes of preventing significant morbidity and mortality, raising awareness about this particular disease and connecting patients with care. Part of this education included us showing the patients how to manually take an accurate pulse reading, and how to differentiate between a normal and irregular rate and rhythm. By teaching the patients these skills, they now know what to look for, how to monitor their own pulse, and when to seek help in the event they, or someone they know, experience symptoms of atrial fibrillation.

BackgroundDespite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs).ObjectiveWe investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence.MethodsIn UK primary care EHR (The Health Information Network 2011–2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed.ResultsAmong 36 652 individuals with incident AF, cardiovascular comorbidities (median CHA2DS2VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of ‘primary non-adherence’ (stopping after first prescription), ‘non-adherent non-persistence’ and ‘persistent adherence’ were 3.5%, 26.5% and 40.2%, differing across OACs.ConclusionsAdherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.

Background Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy. Purpose To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks. Methods 21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained. Results 672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations Conclusions ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF. Acknowledgement/Funding NHS England Test Bed Programme

Aim Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI. Methods and results This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome. Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia). Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388). Conclusion This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data. Acknowledgement/Funding None

Nationally, anticoagulation for atrial fibrillation (AF) is improving but remains characterised by marked provider variation. Uncontrolled blood pressure and coronary artery disease further increase cardiovascular risk. Redbridge Clinical Commissioning Group (CCG) and local National Health Service (NHS) hospital trusts supported a programme to improve anticoagulation, blood pressure and cholesterol management; the ABC of AF improvement.The programme was delivered by a clinical pharmacist in 43 general practices, who used Active Patient Link (APL-AF) software to identify and electronically review the records of AF patients potentially suitable for anticoagulation. These patients were invited for a general practitioner (GP)-pharmacist consultation with initiation of anticoagulation where appropriate. Blood pressure and lipid treatment were also optimised.The university-based Clinical Effectiveness Group (CEG) provided software support using standard data entry templates from which the APL-AF software was enabled. This identified suitable patients (eg, on aspirin monotherapy, no treatment or inappropriate dual treatments) for clinical and treatment review. It also reported real-time overall practice performance. Additionally, GP education on direct oral anticoagulant initiation in general practices, use of software and performance reviews, took place for all practices in Redbridge.A weekly multidisciplinary team (MDT) video conference discussed complex patients with a cardiologist, haematologist, GP with specialist interest in cardiology, GP coordinator and clinical pharmacist. This enabled sharing of patient records between GPs and hospital specialists with improved communication and learning.Over 1 year 2016–2017, anticoagulation in eligible AF patients (CHA2DS2-VASc≥2) increased significantly by 6.3% from 77.0% to 83.3% (pThese methods are being scaled locally in other London CCGs and are potentially scalable nationally, specifically targeting the poorer performing CCGs.

Introduction Direct oral anti-coagulants (DOACs) have been developed that provide simplified, fixed dose regimes over variable dosing with vitamin K anticoagulants. However, DOAC dosing is dependent on indication, demographics and co-morbidities, such as renal impairment. Inappropriate dosing is associated with harm with both unintentional under- and excessive-dosing [1]. The purpose of this study is to describe the appropriateness of DOAC prescribing with respect to the criteria set out in summary of product characteristics (sPC) and British National Formulary [2,3]. Methods A retrospective audit of consecutive in-patients, over a 3-month period, prescribed DOACs in St Bartholomew’s and Royal London hospitals from November 2018 was performed. Data was extracted from electronic healthcare and pharmacy records. Inclusion criteria: prescribed a DOAC (apixaban, dabigatran, edoxaban and rivaroxaban), recorded dose and frequency, patient sex, age and weight; serum creatinine (sCr). Exclusion criteria: use of non-DOAC anticoagulant, record duplication and incomplete records. Dosing appropriateness was compared for each of the drugs with respect to indication and criteria set in individual sPCs. Results 360 patients were prescribed DOACs, of whom 203 (56%) satisfied inclusion/exclusion criteria. Main reasons for non-inclusion were incomplete records (n=54) and record duplication (n=91). Mean age was 76±24 years, with 23% of patients >80 years-old and 15% Conclusion In our university hospital network, more patients were underdosed relative to their indication than was expected. This may be due to usage of clinically available eGFR, which is routinely available as part of hospital systems, rather than using manually calculated CrCl and the multiple criteria required to dose apixaban correctly. Further education of prescribers and ward-based pharmacists is required to improve the prescribing quality with the aim of improving treatment efficacy and safety outcomes. References Yao X, et al. J Am Coll Cardiol 2017;69:2780. www.medicines.org.uk www.bnf.nice.org.uk Conflict of Interest nil

Background Cardiovascular disease (CVD) is the leading cause of mortality worldwide, totalling almost one-third of all deaths. Lipid optimisation is a key public health priority to decrease CVD morbidity, mortality and consequential economic burden on healthcare systems. A reduction in cholesterol by 1 mmol with statin therapy reduces the risk of CVD events by 20%–24%, in people with an estimated 10 year CVD risk greater than 10%. In the UK, the National Institute of Clinical Excellence (NICE) recommends atorvastatin 20 mg for primary prevention of CVD in these people, using QRISK2 to estimate their level of risk. Purpose To assess adherence to NICE lipid modification guidance in patients presenting with acute coronary syndrome (ACS). Material and methods Data on lipid-lowering therapy was collected prospectively, over an 8 week period in August 2018, for all patients presenting with ACS. QRISK2 scores were calculated for patients admitted with ACS naive to statin therapy. Ethics approval was not required. Results Two-hundred and fifty-two patients presented with ACS: mean total cholesterol and low-density lipoprotein (LDL) levels on admission were 4.7 and 2.8 mmol/L respectively. One-hundred and thirty-six (54%) patients were naive to statin therapy prior to admission, of these 91 (67%) had a QRISK2 score greater than 10% (mean 18.45%). All patients were subsequently discharged on high-intensity statins, 124 (91%) on atorvastatin 80 mg. Conclusion Two-thirds of patients naive to statin therapy prior to admission had a 10 year CVD risk of 10% or greater, as estimated using QRISK2, and would have been eligible for atorvastatin 20 mg for primary prevention of CVD as per NICE guidance. Identifying patients in primary care at risk of CVD events is key to ensuring appropriate lifestyle modifications are undertaken and statin therapy initiated, both of which have been shown to reduce CVD event rates. Community services, such as NHS health checks at community pharmacies, and development of GP practice-based pharmacists should be targeted and supported by secondary care to ensure high-risk patients are prescribed optimum lipid modification therapy for primary prevention of CVD, thereby reducing the risk of CVD morbidity, mortality and associated financial implications to the health system. References and/or acknowledgements https://www.nice.org.uk/guidance/cg181/chapter/1-Recommendations#lipid-modification-therapy-for-the-primary-and-secondary-prevention-of-cvd-2 No conflict of interest.

Background The National Institute for Health and Care Excellence (NICE) technology appraisals has made recommendations on four direct oral anticoagulants (DOACs). Local anticoagulation policy recommends all patients newly initiated on a DOAC should be followed-up in an anticoagulation clinic within 4 weeks. There is evidence suggesting that up to 30% of patients are dosed inappropriately according to their age, bodyweight and renal function. Purpose To assess the dosing appropriateness of DOACs at initiation at the 1 month follow-up anticoagulation appointment in the clinic. Determine percentage of patients who are initiated on an appropriate dose. Determine percentage of patients that had an intervention made in their treatment plan at the clinic. Material and methods Data was collected retrospectively over a period of 6 months from patient healthcare records from January 2018 to July 2018 for patients attending anticoagulant clinics. Results Sixty–four per cent (n=118) of patients newly initiated on a DOAC were followed–up within 4 weeks. Ninety–two per cent (n=166) of patients were initiated on an appropriate dose of DOAC in accordance with product licence. Fifteen per cent (n=27) of patients had either a dose or DOAC changed, or DOAC stopped at the follow–up appointment by a pharmacist. The majority of alterations were due to incorrect documentation of weight, use of old blood test results and use of eGFR instead of calculated creatinine clearance (CrCl) using Cockroft and Gault. The majority of patients were followed up within a 4 week period. A significant proportion, 8% (n=17), required dose amendments, as initial dosing was incorrectly based on CrCL estimated by the hospital system which is based on e–GFR and not Cockroft and Gault in line with the product licences and clinical trials. Conclusion Pharmacists have a clear role in ensuring appropriate dosing of DOACs and a reminder (and education) for non-specialist pharmacists on the importance of dosing based on CrCl with Cockroft and Gault, as opposed to the default on hospitals with is e-GFR. Reference and/or acknowledgements Manzoor BS, Cheng WH, Lee JC, et al. Quality of pharmacist-managed anticoagulation therapy in long-term ambulatory settings: a systematic review. Ann Pharmacother 2017;51:1122–37. No conflict of interest.

Background The European Statements of Hospital Pharmacy state that hospital pharmacists should promote seamless care by contributing to the transfer of information about medicines whenever patients move between and within healthcare settings. This is due to the increased risk of unintended medication errors as a result of miscommunication, which contributes to unnecessary hospital admissions. Approximately 5% of hospital admissions are associated with medication errors or misuse, which can sometimes be fatal. Anticoagulants are considered as high-risk medicines due to their association with preventable harm and admission to hospital. Purpose To review the quality of information on discharge summaries to determine if standards for oral anticoagulation were met. Material and methods A retrospective study was undertaken on all adult patients dispensed and discharged on an oral anticoagulant over a 1 month period. Pharmacy dispensing systems were used to identify patients. Short-term anticoagulation e.g. hip/knee patients were excluded from the study. Discharge summaries were reviewed against the following standards set at 100%: Indication. Risk stratification score (CHADSVASc) for atrial fibrillation (AF) indication International Normalised Ratio (INR) range for patients receiving vitamin K antagonist (VKA). For newly initiated patients, follow–up anticoagulation clinic date booked within a given time frame: 5 days for VKA and 30 days for any direct oral anticoagulants (DOACs). Results Three-hundred and forty-eight patients met the inclusion criteria, with 92 patients receiving warfarin and 256 receiving a DOAC. The median age for oral anticoagulation was 77, (70 warfarin, 79 DOACs) of which 137 patients (39%) were newly initiated (10% warfarin, 29% DOAC). All patients had an indication present with 239 patients indicated for AF, with four (1.7%) having a documented CHA 2 DS 2 VASc score. Sixty patients (65%) receiving VKA had a recorded INR range for their therapy. Lastly, 60 (44%) newly initiated patients had any details of their next follow-up appointments. All newly initiated VKA patients had a designated follow-up, with 31 (88.6%) patients having a follow-up within 5 days. Conclusion Variability exists for documentation and recognising the wide applicability of anticoagulation. Pharmacists have an integral role in mitigating the risks associated by ensuring appropriate information is documented for patients when transferred between healthcare settings. References and/or acknowledgements The European Statements of Hospital Pharmacy www.eahp.eu/sites/.../European%20Statements%20of%20Hospital%20Pharmacy.pdf No conflict of interest.

Background Oral anticoagulation therapy has proven beneficial impact on the prevention of thromboembolic events. However, the use of antocoagulatns also increases the risk of bleeds. To maximize the benefits and minimize the risks of the treatment, guidance on appropriate use of oral anticoagulants is essential. An international guideline describing relevant components and requirements for pharmaceutical care for patients receiving a therapy woth oral antocoagulants would increase the quality of care. However, recommendations on pharmaceutical care for patients on anticoagulation is lacking. Objective This study aims to develop an interprofessional guideline to support patients in their use of oral anticoagulation therapy. Method Two systematic literature searches were performed on existing guidelines on the management and interventions to improve-oral anticoagulant use, to generate possible recommendations. Subsequently, an international expert panel with 26 pharmacists with extensive experience in clinical and/or scientific work on anticoagulation from a total of 22 European and 4 non-European countries was constituted. With this (geographically well distributed) expert panel, a four-round internet-based Delphi technique was conducted to reach consensus on their relevance. Items were ranked on a 1–10 scale of agreement. A median agreement score of ≥ 7.5 was considered the threshold for consensus. Levels of importance were rated on a 1–3 scale. Setting A global network of 26 pharmacists specialized in oral antocoagulation therapy. Main outcome measure Development of inter-professional guideline. Results After the four Delphi rounds 18 guideline recommendations were formulated. Consensus of opinion was achieved for all recommendations (median agreement: 8.5–10.0), whereas mean levels of importance were between 1.1 and 2.0 (SD: 0.2–0.7). The following domains were rated as most important targets for improving the care around oral anticoagulation: ‘INR-monitoring’, ‘Transfer of care between health care settings’, ‘Adherence to medication’, ‘Patient communication and engagement’, and ‘Medication reconciliation and medication review’. Conclusion The 18 recommendations included in this guideline provide the base for optimization of anticoagulation care across different countries/healthcare systems. Future work involves translating the guideline recommendations into clinical practice. Once implemented, the recommendations of the guideline will support health care providers with the pharmaceutical care for patients on, oral anticoagulation which will improve the effective and safe use of these medicines. Electronic supplementary material The online version of this article (10.1007/s11096-019-00844-0) contains supplementary material, which is available to authorized users.

Introduction Supraventricular tachycardias (SVTs) are a common cause of acute hospital presentations. Adenosine is an effective treatment. To date, no studies have directly compared paramedic-with hospital-delivered treatment of acute SVT with adenosine. Method Randomised controlled trial comparing the treatment of SVT and discharge by paramedics with conventional emergency department (ED)-based care. Patients were excluded if they had structural heart disease or contraindication to adenosine. Discharge time, follow-up management, costs and patient satisfaction were compared. Results Eighty-six patients were enrolled: 44 were randomised to paramedic-delivered adenosine (PARA) and 42 to conventional care (ED). Of the 37 patients in the PARA group given adenosine, the tachycardia was successfully terminated in 81%. There was a 98% correlation between the paramedics9 ECG diagnosis and that of two electrophysiologists. No patients had any documented adverse events in either group. The discharge time was lower in the PARA group than in the ED group (125 min (range 55–9513) vs 222 min (range 72–26 153); p=0.01), and this treatment strategy was more cost-effective (£282 vs £423; p=0.01). The majority of patients preferred this management approach. Being treated and discharged by paramedics did not result in the patients being less likely to receive ongoing management of their arrhythmia and cardiology follow-up. Conclusions Patients with SVT can effectively and safely be treated with adenosine delivered by trained paramedics. Implementation of paramedic-delivered acute SVT care has the potential to reduce healthcare costs without compromising patient care. Trial registration number NCT02216240.

Oral anticoagulation is the long-term standard of care for preventing stroke in patients with atrial fibrillation (AF). However, anticoagulation is associated with an increased risk of bleeding, such that its use should be based on the absolute risks of stroke and bleeding, and the relative benefit-risk profile of the individual patient. Non-vitamin K antagonist oral anticoagulants, including rivaroxaban, are alternatives to vitamin K antagonists such as warfarin in this setting, and are supported in treatment guidelines as the optimal choice for patients with AF at moderate to high risk of stroke. Rivaroxaban can be given in fixed doses without routine coagulation monitoring, and phase III studies have demonstrated its safety profile and efficacy in patients with non-valvular AF, including the elderly and those with co-morbidities. Moreover, rivaroxaban is administered once daily, which has advantages for optimal patient adherence to medication over the long term. The established efficacy and safety profile of rivaroxaban, together with its convenient once-daily dosing schedule, may contribute to improved patient outcomes and lead to sustained benefits for patients with non-valvular AF at risk of stroke.

Atrial fibrillation (AF) is the most prevalent clinically relevant arrhythmia, affecting millions of individuals in Europe and the USA. Atrial fibrillation increases the risk of stroke; the long-term standard of care for prevention of AF-related stroke is anticoagulation. The use of anticoagulants should be based on the absolute risks of stroke and bleeding and the relative benefit-risk profile of the individual patient. Treatment options include vitamin K antagonists (VKAs) such as warfarin, whose use is long-established but associated with drawbacks, including regular coagulation monitoring requirements and many food and drug interactions. The non-VKA oral anticoagulants are gaining widespread use as alternatives to VKAs, and are supported in treatment guidelines for patients with AF at moderate to high risk of stroke. Adherence to medication is important for the long-term efficacy of any therapy; however, relatively low levels of medication adherence are to be expected in 'real-world' AF patients compared with clinical trials. Experience across several therapy areas, including cardiovascular disease, shows that poor adherence to chronic medication is common. However, simple dosing schedules may be advantageous in this respect, and because long-term outcomes in AF are likely to be influenced by adherence, once-daily dosing has the potential to improve rates of stroke prevention in patients with AF.

The main anticoagulants traditionally prescribed were predominantly vitamin K antagonists, and the more recent introduction of NOACs has increased the options available to patients and the associated potential drug-related problems. Pharmacists can play a vital role in the pharmaceutical care of anticoagulation management from patient education to ongoing clinical monitoring.

Background Guidelines on the management of orally anticoagulated patients are continuously evolving, leading to an increased need for pharmacists to be fully integrated in care provision. Objective To identify self-reported gaps in confidence among practicing pharmacists in the area of anticoagulation. Setting Pharmacists in different work settings in different countries. Method Cross-sectional international survey from October 2015 till November 2016 among pharmacists working in different settings to assess their level of confidence when delivering anticoagulants as well as to identify possible educational needs regarding this medication class. Validation of the survey was ensured. Results Responses from 4212 pharmacists originating from 18 countries were obtained. Pharmacists’ level of confidence was significantly higher (p

Background: The lack of antidotes for direct-oral-anticoagulants (DOACs) means that management of bleeding on DOACs will consist largely of existing therapies. This study aimed to: a) examine the relative frequency of DOAC-related major bleeding in relation to DOAC prescriptions over study period; b) describe the presentation and haematological management of DOAC-related major bleeding; and c) evaluate the association between use of prothrombin-complex-concentrate (PCC) and in-hospital mortality. Methods: Over a three-year period (2013-2016) 32 UK hospitals submitted routine data on haematological management of DOAC-related bleeding. Findings: Data consisted of 421 episodes (67%, 21%, 11% and 1% on rivaroxaban, apixaban, dabigatran and edoxaban respectively) of major bleeding on DOACs. The proportion of major bleeds on DOAC and DOAC prescriptions increased throughout the study. Overall, 44% and 37% of patients presented with gastrointestinal bleeding and intracranial-haemorrhage (ICH) respectively. Factor-specific assays were seldom performed. PCC was the most common treatment (39%) and was more likely to be given for ICH and factor-Xa inhibitor DOACs. Compared to no PCC, receiving ≥3000 IU of PCC was associated with over twofold increase in adjusted cumulative incidence of death (subdistribution hazard ratio: 2.56; 95%CI: 1.46-4.47; p=0.001); there were no statistically significant associations with lower doses. The in-hospital thromboembolic event rate was 1.9% and was not associated with PCC use. Interpretation: There was no evidence of benefit associated with PCC use for major bleeding DOAC patients in terms of in-hospital mortality, and higher doses were associated an increased incidence of death; PCC effects should be further investigated. Funding: The study was funded by the British Society for Haematology Early Stage Researcher Fellowship awarded to Dr Laura Green. Declaration of Interest: All authors declare the following: LG, JT, JM, NC, TE and SS have no conflicts of interest to disclose. AS has received honorarium from from Bayer Healthcare, Daiichi Sankyo, and Portola, outside the submitted work. RA has received honorarium from Bayer, Daiichi-Sankyo, Boehringer Ingelheim and BMS/Pfizer. KS has received honorarium from Bayer, BMS/Pfizer and Boehringer Ingelheim. CT has received honoraria and/or support to attend scientific meetings from Bayer, Pfizer, NovoNordisk, Shire, Sobi, CSL Behring and Daiichi-Sankyo. PM has served as a speaker for Bayer and Daiichi-Sankyo, as a consultant for Daiichi-Sankyo, and has received travel support from Boehringer Ingelheim. Ethical Approval: Ethics approval was obtained for the study from the National Health Service, Health Research Authority (East of England- Cambridge South Research Ethics Committee, reference: 12/EE/0431)

Objectives: To evaluate a prompt card (i.e., a post-card sized tool that lists counselling prompt information) with 5 key elements and 3 open key questions to ask patients in community pharmacies. Methods: Community pharmacists practicing in England and accredited to perform consultations used the prompt card during a formal consultation with emphasis on patients receiving oral anticoagulation. Main outcome measure was the number of performed consultations with pharmacists’ thoughts and feedbacks in writing. Results: During 8 weeks, 19 pharmacists (mean age: 36.6 (SD=9) years; 7 women; accredited an average of 12.9 (SD=9.8) years) performed 1,034 consultations and used the prompt card 104 times during anticoagulation consultations. Overall the prompt card was judged practical and relevant by the 16 pharmacists who used it (100%), especially because it outlines what a good consultation should comprise. The key elements offered a logical framework to guide the overall approach when undertaking a consultation. The two questions, “Why do you want to use this medicine?” and “Why would you not want to use this medicine?” generated negative responses from the patient and pharmacists, respectively. Conclusions: Our prompt card with key questions summarizing all the points that should be addressed in a consultation supported effective communication during patient-pharmacist interaction. Two questions need rephrasing and a further question is needed to determine how patients are using their medicines.

Multiple drug intolerance to antihypertensive medications (MDI‐HTN) is an overlooked cause of nonadherence. In this study, 55 patients with MDI‐HTN were managed with a novel treatment algorithm utilizing sequentially initiated monotherapies or combinations of maximally tolerated doses of fractional tablet doses, liquid formulations, transdermal preparations, and off‐label tablet medications. A total of 10% of referred patients had MDI‐HTN, resulting in insufficient pharmacotherapy and baseline office blood pressure (OBP) of 178±24/94±15 mm Hg. At baseline, patients were intolerant to 7.6±3.6 antihypertensives; they were receiving 1.4±1.1 medications. After 6 months on the novel MDI‐HTN treatment algorithm, both OBP and home blood pressure (HBP) were significantly reduced, with patients receiving 2.0±1.2 medications. At 12 months, OBP was reduced from baseline by 17±5/9±3 mm Hg (P

AF-related strokes represent a significant burden to patients, their carers and the NHS. New guidance from the National Institute for Health and Care Excellence (NICE) emphasises the importance of undertaking stroke-risk assessment and the initiation of anticoagulant therapies to reduce this burden. Currently, in primary care, there are a substantial number of patients with AF who are not anticoagulated, being prescribed nothing or aspirin only. A systematic approach to identifying and addressing this unmet need is required in primary care. This article discusses some of the barriers to achieving better stroke prevention in AF and suggests strategies to address these. In addition, the recommended stroke- and bleeding-risk tools are described alongside an explanation of how they can be used in clinical practice.