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In this discussion, Megan LaBreck, PharmD, BCPS, CACP, and Kristen Campbell, PharmD, BCPS, CPP, discuss the role of the pharmacist in electrophysiology (EP), current challenges in antiarrhythmic drug therapy, and pharmacist-led educational intervention.

Kristen Campbell, PharmD, BCPS, CPP: Hi everyone, I am Kristen Bova Campbell. I am a clinical pharmacist at Duke University Hospital. 

Megan LaBreck, PharmD, BCPS, CACP: I am Megan LaBreck. I am a clinical pharmacist at OhioHealth Riverside in Columbus, Ohio. 

Campbell: Why don't you tell me a little about what you do in your role? 

LaBreck: I currently see patients in our outpatient Antiarrhythmic Clinic, and these patients are either new starts on antiarrhythmic drugs or continuations of therapy. I see them in conjunction with our physicians, in an alternating fashion, helping to offset some of that work of the physician. I routinely follow up with their QT when on drugs. The patient gets an electrocardiogram (ECG) every 6 months, and every year meets with me and the physician. I am also longitudinally monitoring their labs, ensuring the appropriateness of their refills, making sure the doses of their medications are appropriate, specifically class III drugs. When doing that, I also look at their anticoagulation, making sure their direct-acting oral anticoagulants (DOACs) are appropriately dosed. Or, if they are not on appropriate therapy for whatever reason, recommending that to the physician. What about you? 

Campbell: I do a little of that as well. I have an outpatient clinic and help manage antiarrhythmics and monitoring. In North Carolina, pharmacists can actually have a role as a clinical pharmacist practitioner where we set up protocols, very similar to that of physician assistants (PAs) and nurse practitioners (NPs). So, my protocol also allows for management of anticoagulation, hypertension, and heart failure to try to keep people euvolemic and things like that when they are in front of their provider. I also round with the inpatient service at Duke. We have a rounding service as well as a consult service. I round with the inpatient service, see consults on an as-needed basis, and work as a liaison for the lab to help make sure that we are using all medications appropriately and everything is appropriately stocked, and so on.

LaBreck: It gets really complex, inpatient/outpatient.

Campbell: Yes, it does, but I love it. I love the care of EP patients and being involved in their management. 

LaBreck: I think that is my favorite part as well. It is such a complex disease state, and our patients get more complex as we see them. What do you think is one of your biggest challenges? 

Campbell: I think it is the complexity and the idea of having to think outside the box with our patients. I work with other disciplines like oncology and infectious disease, and they will reach out to us saying they need to use a particular medication in this patient. Sometimes we will have to say, “but we finally got their atrial fibrillation (AF) controlled on this antiarrhythmic and there is a lot of interactions.” So, working together and collaborating to try and do what is best for the patient and keep them safe is really important. 

LaBreck: In my role I am super grateful for the value I bring to our team, and I feel that every day. Our team really relies on me to direct drug interactions and how to guide therapy in that regard. So, like you mentioned, working with the multidisciplinary teams for our patients in hematology, patients in the MS clinic[JE1] , or patients being treated by various other subspecialties, is really important. I also think it is a really good opportunity for us as pharmacists to see these patients in the outpatient setting to provide reeducation about the disease state. In our AF clinic, our advanced practice providers (APPs) do a really good job of education up front. But over time, as the disease state progresses, we can provide reeducation to patients that this is a progression of their disease state and not necessarily anything they did wrong. 

Campbell: Absolutely. It is also just a reminder of things. I cannot even tell you how many times I have had patients send us a message or say to us in clinic that they were about to take this medication that they received in the emergency department, and they could hear my voice saying not to take anything until they have checked to make sure it was alright to take. I think that having a pharmacist see them at regular intervals really helps to drive home those points and keep our patients safe. 

LaBreck: Yes, I agree 100%. Having face-to-face communication with somebody who is not a physician can also help lower a barrier, especially since we may have a little more time to spend with the patient. I think that helps build trust with the team, and the patients tend to reach out more and ask more questions. It is important that patients are engaged in their own care.

Campbell: Yes, I am really lucky in that because I round on the inpatient service, I provide that continuity a lot of times for patients. For example, if they come in for a dofetilide load or anything like that, then they see me in clinic and I am often the only one that is connecting them from that inpatient to the outpatient experience, because it is not common that a patient will come in when their attending is rounding during their drug load. So, that familiarity of both facial recognition and knowing I took care of them while they were an inpatient helps them to feel more comfortable asking questions since they recognize me. I think that goes a long way and strengthens our entire model. I believe it helps the patient feel like they are really being cared for by all the members of the team.

LaBreck: I agree. When the AF guidelines were updated at the end of last year, the comprehensive care model really should be something that our institutions across the United States focus on, especially with adding a pharmacist, because it is such an underutilized skillset and not only for transition of care. I cannot tell you how many times I have seen outside providers restart a contraindicated medication post-dofetilide load. Our consult EP service at discharge will even place a signoff note, but the discharging provider will generally do 30 days with no refills. Therefore, the patient should have further education about their meds. They receive initial education in the inpatient setting, but there is often such a large amount of knowledge or information dropped on them at one time, that it is easy to forget some of those things. 

Campbell: They cannot remember everything that they have been told.

LaBreck: Exactly. So, I recommend to have somebody be a checkpoint. For our drug load patients, my appointment with them is like a specific transition. I see new drug loads within 4 to 6 weeks. I cover questions such as how they are tolerating this, if they are having trouble obtaining medication from a cost standpoint, the importance of monitoring, why we monitor, and what we monitor. I also discuss medications that are interacting, absolute contraindications, and possible other interactions. I give them my number and contact information, including information on MyChart messaging. My goal is to make sure that their medication use remains safe. I remind them why they were just in the hospital and tell them to make sure that their other providers are aware that they are on dofetilide. I want to empower the patient to be a part of their own care and make sure that they are taking medications that are safe.

Campbell: I completely believe in that. That is probably what I try to drive home as the most important thing during my inpatient teaching sessions, because I know they are not going to remember a lot of the information given to them in the hospital. If they walk away with anything, it is to know that they need to ask questions. I think another common mistake that is understandable for patients is to assume that if they are in the health care system that everybody will be on the same page; the reality is that we all have focused eyelines on what we are looking at and so even though it is in that electronic health record (EHR), it is still really important for the patient to advocate for themselves and say, “I am on this medication, I need to know that you have seen that and you are making your decisions based on that.” 

LaBreck: Absolutely. Also, everyone knows but I think we forget that antiarrhythmic drugs and anticoagulation are 2 super high-risk areas and should never be taken lightly. We need to remind ourselves that these medications can cause death. It is really about the patients' lives. We must think about and create our teams around that with the patient at the center. We have all seen the visuals of patients who have many complex comorbidities. We have pharmacists in our diabetes management, hypertension, and anticoagulation clinics, but if we are going to provide comprehensive care to our patients with AF, we need to have somebody at the center of care. 

Campbell: Absolutely. 

LaBreck: I think that that is a good kind of liaison, like you mentioned with the EP lab being a liaison to the patient and other specialties[JE2] , helping that communication pathway and connecting the dots for people—not only providers but patients as well. 

Campbell: When I first started with EP, a physician told me, “Besides oncology, we are using the most dangerous drugs.” He continued, “I do not understand why every practice does not have a pharmacist.” So, I think you made the absolute argument that there should be more people like us. We are pretty few and far between. 

LaBreck: I like to call us the “unicorn” care team, but I think that as we hopefully get more people like us within societies such as the Heart Rhythm Society or even local American College of Cardiology (ACC) chapters, we can make a huge impact, and education goes a long way. 

Campbell: Absolutely, I agree with you. Well, it was really great talking to you. I am so glad to hear about your practice. 

LaBreck: It was really great talking to you, too. I am glad we got to meet up.

Campbell: Thank you!

The transcripts have been edited for clarity and length.