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BACKGROUND The gap in anticoagulation (AC) use among patients with atrial fibrillation (AF) is a major public health threat. Inadequate patient education contributes to this gap. Patient portal-based messaging linked to educational materials may help close this gap but the best messaging approach is unknown. OBJECTIVE To compare responsiveness of patients to two portal messaging approaches at two different health systems: targeted messaging 1 week before outpatient appointment vs. sending messages all in one blast. METHODS Using the two approaches, we sent messages to high risk patients on and off AC as well as those at low risk who may become eligible for AC in the future (where risk was classified based on CHA2DS2-VASC score). The messages contained a link to Upbeat.org, a website of the Heart Rhythm Society which has print and video materials about AF and AC. We then tracked message opening, review of the website, and AC use across messaging approaches/sites adjusting for potential confounders. RESULTS We sent 1672 targeted messages and 1450 blast messages. Message opening was significantly higher with the targeted approach for patients on AC (64% versus 57% p value 0.005) and trended the same in patients off AC; subsequent website review was not different by messaging approach. More patients off AC at baseline started AC with the targeted approach (adjusted percentage 9.3% vs. 2.1% p < 0.001). CONCLUSIONS Patients were more responsive in terms of message opening and subsequent AC initiation with the targeted approach. Non-random allocation of the intervention limits firm conclusions.

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