Clot Chronicles: AF-ALERT Trial with Dr. Gregory Piazza

Dr. Gregory Piazza hosts the Clot Chronicles this week, discussing his recent AF-ALERT trial.

Hi, my name is Gregory Piazza. I am one of the vascular medicine cardiologists at Brigham and Women’s Hospital. This morning I am going to tell you about a research study that we did at the Thrombosis Research Group called the AF-ALERT trial. This was a study that was designed to see how we could improve on under-utilization of preventive measures in patients who had atrial fibrillation and were at risk for stroke. We know that atrial fibrillation increases the risk of stroke in our patients and that many of these patients require anticoagulation to prevent stroke.

In a study that we did earlier that looked at rates of anticoagulation at Brigham and Women’s Hospital, we found that there were many patients who had indications for anticoagulation but weren’t being provided with this important preventive measure. So we designed a randomized control trial looking at a computerized alert that would appear on screen while the providers were writing orders for their patients if the patient had atrial fibrillation, was at increased risk for stroke, and wasn’t already being written for anti-thrombotic or anticoagulant therapy. We randomized over 450 patients and the patients who were in the alert group had their providers receive an onscreen alert notifying them that the patient had atrial fibrillation, had an increased risk for stroke, and wasn’t being provided with the guideline recommended appropriate anticoagulant therapy. For patients in the control group, or no alert trial, there was no notification sent to their provider.

What we found was that the computerized alert was able to increase utilization or prescription of anticoagulation, not just while the patient was in the hospital but also when the patient was being discharged and also at 90 days. So the alert had a very nice effect of teaching providers about the need for anticoagulation and then making sure that the patient stayed on anticoagulation up to 90 days. What was very interesting about the study is we also found that patients assigned to the alert, there was a reduction in the risk of heart attack and stroke, and that overall major cardiovascular events were prevented in those for whom an alert was sent to the provider. We suspect that some of that impact is from increased prescriptions of anticoagulation, but the electronic alert may also have had off-target effects, such as notifying providers to reduce other cardiovascular risk factors, like managing the blood pressure, treating cholesterol, making sure the patients did all of the other lifestyle changes that are necessary to prevent heart attack and stroke.

We look forward to looking at a similar type of alert in outpatients that are seen in the clinic to see if we have the same effect. These trial results were presented at the American Heart Association in 2018, just a few months ago, and we are very excited to go forward to apply computerized-decision support techniques to improve care in other trials. Thank you.