Alert-based computerized decision support for high-risk hospitalized patients with atrial fibrillation not prescribed anticoagulation: a randomized, controlled trial (AF-ALERT).

AIMS: Despite widely available risk stratification tools, safe and effective anticoagulant options, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is underprescribed. We created and evaluated an alert-based computerized decision support (CDS) strategy to increase anticoagulation prescription in hospitalized AF patients at high risk for stroke. METHODS AND RESULTS: We enrolled 458 patients (CHA2DS2-VASc score ≥1) with AF who were not prescribed anticoagulant therapy and were hospitalized at Brigham and Women's Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) vs. control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. The CDS tool assigned 248 patients to the alert group and 210 to the control group. Patients in the alert group were more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%, P < 0.0001), at discharge (23.8% vs. 12.9%, P = 0.003), and at 90 days (27.7% vs. 17.1%, P = 0.007). The alert reduced the odds of a composite outcome of death, myocardial infarction (MI), cerebrovascular event, and systemic embolic event at 90 days [11.3% vs. 21.9%, P = 0.002; odds ratio (OR) 0.45; 95% confidence interval (CI) 0.27-0.76]. The alert reduced the odds of MI at 90 days by 87% (1.2% vs. 8.6%, P = 0.0002; OR 0.13; 95% CI 0.04-0.45) and cerebrovascular events or systemic embolism at 90 days by 88% (0% vs. 2.4%, P = 0.02; OR 0.12; 95% CI 0.0-0.91). CONCLUSION: An alert-based CDS strategy increased anticoagulation in high-risk hospitalized AF patients and reduced major adverse cardiovascular events, including MI and stroke. CLINICALTRIALS.GOV IDENTIFIER: NCT02339493.

Anticoagulation and Mortality Rates among Hospitalized Patients with Atrial Fibrillation.

Atrial fibrillation (AF) is associated with an increased rate of mortality, heart failure, and stroke. We conducted an observational study to assess the relationship between anticoagulation and adverse clinical outcomes in hospitalized patients with AF. We performed a 5,000-consecutive-patient retrospective cohort analysis of anticoagulation prescription and 90-day outcomes in patients with AF hospitalized at Brigham and Women's Hospital from May 2008 to September 2014. All-cause mortality at 90 days was 5.4%. The frequency of death between hospital discharge and day 90 was lower in patients who were anticoagulated at discharge (2.8 vs. 7.1%, p < 0.001). Anticoagulation prescription at discharge was associated with a 60% reduction in death between discharge and day 90, after adjustment for confounding factors. Major adverse events at day 90, including death, myocardial infarction, stroke, and major bleeding, were more frequent in patients who were not prescribed anticoagulation at discharge (16.5 vs. 10.4%, p < 0.001). In multivariable regression analysis, prescription of anticoagulation at discharge predicted a lower mortality (adjusted odds ratio (OR), 0.4; 95% confidence interval (CI), 0.3-0.53) and lower major adverse event rate (adjusted OR, 0.64; 95% CI, 0.54-0.76) by day 90. In conclusion, all-cause mortality at 90 days was high among inpatients with AF. Patients with AF who were not prescribed anticoagulation at discharge had an increased risk of death at 90 days. Hospitalization represents a special opportunity to optimize cardiovascular risk reduction strategies, including anticoagulation.