Practice spotlight: pharmacists in a multidisciplinary atrial fibrillation clinic.

The St Paul’s Hospital Atrial Fibrillation Clinic opened in October 2009 with the mandate of streamlining care for patients with atrial fibrillation who have had suboptimal response to standard therapies and therefore require more complex medication management and/or radiofrequency ablation. The proven benefits of this treatment modality have resulted in broader use and hence long waiting lists for the procedure. It was anticipated that a multidisciplinary approach to care would increase patients’ access to clinicians familiar with the various treatment options. Therefore, the clinic employs a registered nurse, a nurse practitioner, and a clinical pharmacist (with Sonia Basi and Christine Yu sharing the clinical pharmacist role), all of whom work closely with a team of electrophysiologists. Each discipline utilizes the full extent of its professional authorities for triaging, selection of treatment, and follow-up. Atrial fibrillation clinics successfully using this multidisciplinary approach at other sites in Canada, the United States, and the United Kingdom have been described in the literature. However, for the St Paul’s Hospital Atrial Fibrillation Clinic, the specific roles and activities for each discipline were developed in house, since this was the first such clinic in the province of British Columbia. Cardiologists make most referrals to the clinic, but patients may also be referred by general internists, family phys icians, other electrophysiologists, or emergency physicians. The clinic nurse conducts a brief triage interview by telephone with each patient to assess the severity and urgency of symptoms. All patients with documented atrial fibrillation or flutter are entered into clinic care and scheduled for an hour-long group education session run by the nurse and the clinical pharmacist. Topics covered in the session include the pathophysiology of atrial fibrillation, signs and symptoms, efficacy and toxicity of commonly used medications, and value and role of various treatment procedures, including radiofrequency ablation. This information enables the patient to have a more informed discussion with one of the clinic’s electrophysiologists and facilitates collaborative decision-making regarding treatment. During a patient’s initial on-site visit to the clinic, he or she is seen first by a nurse or nurse practitioner, who conducts a physical examination and obtains the medical and medication history. Next, one of the electrophysiologists interviews the patient for consideration of treatment options. If the history suggests a complicated medication history, the clinical pharmacist also participates in this session. Treatment options are discussed with the patient, and a treatment course is chosen. For initiation of new medications or changes to existing regimens, decisions typically represent a collaborative effort involving the pharmacist, the electrophysiologist, and the patient. The pharmacist counsels the patient about any new medications before the clinic visit ends. Follow-up, conducted primarily by the pharmacist and the nurse practitioner, depends on the treatment course prescribed and the severity of symptoms. About 40% of the patients seen at the clinic undergo radiofrequency ablation; therefore, much of the pharmacist’s time is spent ensuring that the medication regimen is appropriate in the periablation period. All patients who undergo ablation receive anticoagulation, unless it is contraindicated. The pharmacist is responsible for adjusting the dose of warfarin, as well as ordering and interpreting the results of international normalized ratio (INR) tests. Careful dose titration is required, because the clinic electrophysiologists prefer to perform ablation when the INR is between 2.0 and 2.5 (on the basis of published evidence and personal preference). The pharmacist contacts the patient 1 week after the procedure to continue anticoagulation management, and the nurse practitioner follows up 3 months after ablation, consulting the pharmacist if there are any medication-related questions. Many patients are maintained on antiarrhythmic agents in the postablation period, so follow-up often includes discussion about the efficacy of and adverse events associated with these