Elsevier

Thrombosis Research

Volume 227, July 2023, Pages 1-7
Thrombosis Research

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

https://doi.org/10.1016/j.thromres.2023.05.006Get rights and content
Under a Creative Commons license
open access

Highlights

  • Computer alerts may improve stroke prevention in atrial fibrillation (AF).

  • Computer alerts versus no notification was assessed in 798 clinic patients with AF.

  • Computer alerts doubled prescription of anticoagulation.

  • We observed no difference in stroke, TIA, or systemic embolic events.

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 CHA2DS2VASc 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.

Abbreviations

AF
atrial fibrillation
BPA
Best Practice Advisory
BWH
Brigham and Women's Hospital
CDS
computerized decision support
DOAC
direct oral anticoagulant
EHR
electronic health record
ISTH
International Society on Thrombosis and Haemostasis
LMWH
low-molecular weight heparin
MI
myocardial infarction
VTE
venous thromboembolism

Keywords

Anticoagulation
Antithrombotic therapy
Atrial fibrillation
Computerized decision support
Electronic alerts
Stroke

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