Yıl: 2020 Cilt: 48 Sayı: 3 Sayfa Aralığı: 289 - 303 Metin Dili: İngilizce DOI: doi: 10.5543/tkda.2020.16359 İndeks Tarihi: 15-11-2020

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases

Öz:
Objective: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial f ibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. Methods: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. Conclusion: This expert consensus of cardiologists aimed to def ine management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions.
Anahtar Kelime:

Zorlu atriyal fibrilasyon olgularında non-vitamin K antagonisti oral antikoagülan kullanımına güncel klinik yaklaşımlar

Öz:
Amaç: Non-Vitamin K antagonisti oral antikoagülanların (NOAK) geliştirilmesi ve yaygın klinik kullanıma girmesi ile Atriyal fibrilasyonda (AF) inmeden korunmanın ufku değişmiştir. Her ne kadar dört NOAK, büyük çaplı Faz 3 klinik denemeler ile düzenleyici otoritelerden alarak pazar erişim sürecini tamamlasa da Faz 3 denemelerin eksternal validasyonuna ilişkin geleneksel zorluklar günlük pratikte klinisyenleri zorlu olgu ve klinik senaryolar ile karşı karşıya bırakmaktadır. Günlük pratiklerinde klinisyenler, sıklıkla söz konusu Faz 3 denemelerde yeterince temsil edilmemiş ve yeterli kanıtın bulunmadığı hasta grupları ile yüz yüze kalmaktadır. Bu yazıda, pivot NOAK denemelerinde yeterince temsil edilmeyen ancak günlük pratikte sıklıkla karşılaşılan AF olgularının yönetimi ile ilgili olarak, günlük pratikte bu AF olgularının takip ve tedavisini sürdüren 12 kardiyoloji akademisyeninin katıldığı toplantı raporu sunulmaktadır. Yöntemler: Zorlu AF olgularının yönetim stratejilerini tartışmak için bir danışma kurulu paneli toplanmıştır. Mevcut makale bu toplantıdaki olgu sunumları ve tartışmaların özeti olarak derlenmiştir. Sonuç: Kardiyologların bu uzman fikir birliği, rutin uygulamalarından olgu örnekleri kullanarak, önemli çalışmalarda yeterince temsil edilmeyen zorlu olguların yönetim stratejilerini tanımlamayı amaçlamıştır. Güçlü kanıtlar eksik olmakla birlikte, faz çalışmaların alt grup analizleri, bu hastaların yönetimini hakkında kısmen bilgi vermektedir. Bununla birlikte alt grup analizlerinin hipotez kanıtlayıcı değil hipotez oluşturucu doğası unutulmamalı, ihtiyaç duyulan kanıtların elde edilmesine yönelik uygun tasarlanmış deneme/çalışmaların gerçekleştirilmesi gerekliliği göz önünde bulundurulmalıdır. Bu süreç, klinisyenlerin NOAK’ları yalnızca klinik deneyimlerine dayanarak “off label” kullanmasının da önüne geçecektir.
Anahtar Kelime:

Belge Türü: Makale Makale Türü: Olgu Sunumu Erişim Türü: Erişime Açık
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APA ÖNSEL TÜRK U, Acar R, AKGÜN T, EMREN V, KANAT S, KARACAĞLAR E, KEPEZ A, KUL Ş, ÖZEL E, ŞİMŞEK E, TÜLÜCE YAKAR S, TÜLÜCE K, CAMM A (2020). Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. , 289 - 303. doi: 10.5543/tkda.2020.16359
Chicago ÖNSEL TÜRK Uğur,Acar Rezzan Deniz,AKGÜN Taylan,EMREN Volkan,KANAT Selçuk,KARACAĞLAR Emir,KEPEZ Alper,KUL Şeref,ÖZEL Erdem,ŞİMŞEK Evrim,TÜLÜCE YAKAR Selcen,TÜLÜCE Kamil,CAMM A. John Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. (2020): 289 - 303. doi: 10.5543/tkda.2020.16359
MLA ÖNSEL TÜRK Uğur,Acar Rezzan Deniz,AKGÜN Taylan,EMREN Volkan,KANAT Selçuk,KARACAĞLAR Emir,KEPEZ Alper,KUL Şeref,ÖZEL Erdem,ŞİMŞEK Evrim,TÜLÜCE YAKAR Selcen,TÜLÜCE Kamil,CAMM A. John Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. , 2020, ss.289 - 303. doi: 10.5543/tkda.2020.16359
AMA ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. . 2020; 289 - 303. doi: 10.5543/tkda.2020.16359
Vancouver ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. . 2020; 289 - 303. doi: 10.5543/tkda.2020.16359
IEEE ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A "Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases." , ss.289 - 303, 2020. doi: 10.5543/tkda.2020.16359
ISNAD ÖNSEL TÜRK, Uğur vd. "Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases". (2020), 289-303. https://doi.org/doi: 10.5543/tkda.2020.16359
APA ÖNSEL TÜRK U, Acar R, AKGÜN T, EMREN V, KANAT S, KARACAĞLAR E, KEPEZ A, KUL Ş, ÖZEL E, ŞİMŞEK E, TÜLÜCE YAKAR S, TÜLÜCE K, CAMM A (2020). Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Türk Kardiyoloji Derneği Arşivi, 48(3), 289 - 303. doi: 10.5543/tkda.2020.16359
Chicago ÖNSEL TÜRK Uğur,Acar Rezzan Deniz,AKGÜN Taylan,EMREN Volkan,KANAT Selçuk,KARACAĞLAR Emir,KEPEZ Alper,KUL Şeref,ÖZEL Erdem,ŞİMŞEK Evrim,TÜLÜCE YAKAR Selcen,TÜLÜCE Kamil,CAMM A. John Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Türk Kardiyoloji Derneği Arşivi 48, no.3 (2020): 289 - 303. doi: 10.5543/tkda.2020.16359
MLA ÖNSEL TÜRK Uğur,Acar Rezzan Deniz,AKGÜN Taylan,EMREN Volkan,KANAT Selçuk,KARACAĞLAR Emir,KEPEZ Alper,KUL Şeref,ÖZEL Erdem,ŞİMŞEK Evrim,TÜLÜCE YAKAR Selcen,TÜLÜCE Kamil,CAMM A. John Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Türk Kardiyoloji Derneği Arşivi, vol.48, no.3, 2020, ss.289 - 303. doi: 10.5543/tkda.2020.16359
AMA ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Türk Kardiyoloji Derneği Arşivi. 2020; 48(3): 289 - 303. doi: 10.5543/tkda.2020.16359
Vancouver ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Türk Kardiyoloji Derneği Arşivi. 2020; 48(3): 289 - 303. doi: 10.5543/tkda.2020.16359
IEEE ÖNSEL TÜRK U,Acar R,AKGÜN T,EMREN V,KANAT S,KARACAĞLAR E,KEPEZ A,KUL Ş,ÖZEL E,ŞİMŞEK E,TÜLÜCE YAKAR S,TÜLÜCE K,CAMM A "Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases." Türk Kardiyoloji Derneği Arşivi, 48, ss.289 - 303, 2020. doi: 10.5543/tkda.2020.16359
ISNAD ÖNSEL TÜRK, Uğur vd. "Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases". Türk Kardiyoloji Derneği Arşivi 48/3 (2020), 289-303. https://doi.org/doi: 10.5543/tkda.2020.16359