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Undiagnosed Non-Valvular Atrial Fibrillation: A Pharmacist’s Guide to Improving Identification and Management for Stroke Prevention (Webinar Archive)
This educational activity is sponsored by Postgraduate Healthcare Education, LLC (PHE) and supported by an educational grant from Bristol Myers Squibb and the Pfizer Alliance.
Brian T. Cryder, PharmD, BCACP
Associate Professor of Pharmacy Practice
Midwestern University College of Pharmacy
Downers Grove, IL
Advocate Medical Group
Dr. Cryder has disclosed that he has no actual or potential conflicts of interest in relation to this program.
The clinical reviewer, Tracy Macaulay, PharmD, has disclosed that she has no actual or potential conflicts of interest related to this program.
Susanne Batesko, RN, BSN, Robin Soboti, RPh, and Susan R. Grady, MSN, RN as well as the planners, managers, and other individuals, not previously disclosed, who are in a position to control the content of Postgraduate Healthcare Education (PHE) continuing education (CE) activities hereby state that they have no relevant conflicts of interest and no financial relationships or relationships to products or devices during the past 12 months to disclose in relation to this activity. PHE is committed to providing participants with a quality learning experience and to improve clinical outcomes without promoting the financial interests of a proprietary business.
Postgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Credits: 1.5 hour (0.15 ceu)
Type of Activity: Application
Fee Information: There is no fee for this educational activity.
Estimated time to complete activity: 90 minutes
December 16, 2021
December 7, 2022
Health-system pharmacists and other pharmacists who may manage patients with undiagnosed Non-Valvular Atrial Fibrillation (NVAF).
HOW TO OBTAIN CREDIT
During the period December 16, 2021 to December 7, 2022, participants must 1) read the learning objectives and faculty disclosures; 2) view the educational activity; and 3) complete the posttest and evaluation form directly after the activity within a maximum of 60 days of participating in the activity. To answer the questions, click on your selected choice for each answer then proceed to the next question. Once completed, click on the Grade Exam button at the bottom of the page. Your posttest will automatically be graded. If you successfully complete the posttest (score of 70% or higher), your statement of participation will be made available immediately. Click on the View Statement of Participation link and print the statement for your records. If you receive a score lower than 70%, you will receive a message notifying you that you did not pass the posttest. You will have 2 opportunities to pass the posttest. To receive Credit, you must provide your date of birth and NABP number. All Credit information will be uploaded into CPE monitor within 30 days.
To educate health-system pharmacists on the burden and consequences of undiagnosed and untreated Non-Valvular Atrial Fibrillation (NVAF), improve the identification of undiagnosed NVAF, and effectively manage patients with NVAF in order to reduce the risk of preventable stroke.
Upon completion of this program, participants should be better able to:
- Explain the implications of undiagnosed/untreated NVAF and discuss the various types of screening methods for AF
- Discuss principles of stroke prevention in newly diagnosed NVAF
- Compare pharmacological characteristics, efficacy, and safety profiles of oral anticoagulants used for stroke prevention in NVAF
- Formulate individualized, evidence-based anticoagulation plans for newly diagnosed/previously untreated patients with NVAF using a shared decision-making process
Updates: January 12, 2022
|Slide 11: Screening for AF
||The April 2021 US Preventive Services Task Force (USPSTF) recommendations for Screening for Atrial Fibrillation are Draft Recommendations, that as of January 3, 2022, have not been approved.
Note: These recommendations are consistent with the most recently approved 2018 USPSTF recommendations.1
1. US Preventive Services Task Force. Screening for atrial fibrillation with electrocardiography: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(5):478-484. doi:10.1001/jama.2018.10321
|Slide 13: Screening for AF
||Mechanism for Patch:
Electrocardiogram (ECG) patch can be worn from 7-14 days, providing the patient some flexibility.
|Slide 22: Balancing Risks and Benefits
||Clarification: “High-dose” vs “Low-dose” new oral anticoagulants (NOACs)
“High-dose” or “standard clinical study dose" NOACs
• Apixaban 5 mg BID
• Dabigatran 150 mg BID
• Edoxaban 60 mg once daily
• Rivaroxaban 20 mg once daily
"Low-dose" or "reduced clinical study dose" NOACs
• Apixaban 2.5 mg BID
• Dabigatran 110 mg BID
• Edoxaban 30 mg once daily
• Rivaroxaban 15 mg once daily
|Slides 64 & 65: Periprocedural Management
While slides 64 and 65 focus on the management of warfarin interruption for procedures, it is helpful to acknowledge the different approaches needed with NOACs. The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study demonstrated that NOAC interruption duration should be adjusted based on the procedure’s bleeding risk (high- vs low-risk) and the patient’s renal function (for dabigatran specifically) to maintain safety.1 Most NOAC medications can be omitted for 24 hours in low bleeding risk procedures, while holding 48 hours is recommended for higher bleed risk procedures, and dabigatran requires longer interruptions in lower renal function patients (up to 4 days).1
High bleeding risk procedures tend to be more invasive and include major surgery with extensive tissue injury; cancer surgery; major orthopedic surgery; reconstructive plastic surgery; surgery in high vascular organs (kidneys, liver, spleen); cardiac, intracranial, spinal, and most urologic or gastrointestinal (GI) surgeries; plus any procedure with duration >45 minutes.2 Low bleeding risk procedure examples include GI endoscopy, colonoscopy, laparoscopic cholecystectomy, hernia repair, hemorrhoidal surgery, bronchoscopy, shoulder/foot/hand surgeries, and cutaneous/lymph node biopsies.2 This timeline of NOAC interruption is corroborated by Merli et al’s findings that apixaban was almost fully cleared from patients’ bloodstream (≤30 ng/mL) 94% of the time with a 48-hour omission of dosing.3
1. Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA InternMed. 2019;179(11):1469-1478. doi:10.1001/jamainternmed.2019.2431
2. Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost. 2016;14(5):875-885. doi:10.1111/jth.13305
3. Merli GJ, Kraft WK, Eraso LH, et al. Apixaban Discontinuation for Invasive Or major Surgical procedures (ADIOS): a prospective cohort study. Vasc Med. 2021 Nov 22; 1358863X211047270. Epub ahead of print. doi:10.1177/1358863X211047270
REQUIRED COMPUTER HARDWARE/SOFTWARE
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Disclosure of Unlabeled Use and Disclaimer
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of Postgraduate Healthcare Education, LLC. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions, and possible contraindications on dangers in use, (review of any applicable manufacturer's product information) and comparison with recommendations of other authorities.
The author, sponsor, and publisher of this continuing education activity have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. However, because information regarding drugs (their administration, dosages, contraindications, adverse reactions, interactions, special warnings, precautions, etc.) is subject to constant change, the reader is advised to check the manufacturer's package insert for information concerning recommended dosages and potential problems and cautions prior to dispensing or administering the drug. Special precautions should be taken when a drug is new, or highly toxic, or is unfamiliar to the dispenser or administrant. This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the U.S. Food and Drug Administration (FDA). Neither the publisher nor sponsor promotes the use of any agent outside of approved labeling. Statements made in this activity have not been evaluated by the FDA. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.