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Randomized Controlled Trial
. 2023 Jul:227:1-7.
doi: 10.1016/j.thromres.2023.05.006. Epub 2023 May 11.

Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2)

Gregory Piazza  1 , Shelley Hurwitz  2 , Umberto Campia  3 , Behnood Bikdeli  4 , Junyang Lou  3 , Candrika D Khairani  3 , Antoine Bejjani  3 , Julia E Snyder  3 , Mariana Pfeferman  3 , Briana Barns  3 , Samantha Rizzo  5 , Alexandra Glezer  3 , Samuel Z Goldhaber  3
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Free article
Randomized Controlled Trial

Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2)

Gregory Piazza et al. Thromb Res. 2023 Jul.
Free article

Abstract

Background: Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial.

Methods: Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription.

Results: The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days.

Conclusions: An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes.

Trial registration: ClinicalTrials.gov Identifier- NCT02958943.

Keywords: Anticoagulation; Antithrombotic therapy; Atrial fibrillation; Computerized decision support; Electronic alerts; Stroke.

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Conflict of interest statement

Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Piazza has received research support from Bristol-Myers Squibb/Pfizer Alliance, Bayer, Janssen, Alexion, Amgen and Boston Scientific Corporation, and consulting fees from Pfizer, Boston Scientific Corporation, Janssen, and Amgen. Dr. Goldhaber has received research support from Bristol-Myers Squibb, Boston Scientific Corporation, Johnson & Johnson, and Janssen and consulting fees from Bristol-Myers Squibb. Dr. Bikdeli receives support from the IGNITE Award from the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital and a Career Development Award from the American Heart Association and receives fees from consulting as an expert on behalf of plaintiffs for litigation related to inferior vena cava filters. Drs. Campia, Lou, Bejjani, Khairani, and Hurwitz and Ms. Snyder, Ms. Barns, Ms. Glezer, Ms. Rizzo, and Ms. Pfeferman have no conflicts of interest to disclose.

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