Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases [Turk Kardiyol Dern Ars]
Turk Kardiyol Dern Ars. 2020; 48(3): 289-303 | DOI: 10.5543/tkda.2020.16359

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

Uğur Önsel Türk1, Rezzan Deniz Acar2, Taylan Akgün2, Volkan Emren3, Selçuk Kanat4, Emir Karacağlar5, Alper Kepez6, Şeref Kul7, Erdem Özel8, Evrim Şimşek9, Selcen Yakar Tülüce3, Kamil Tülüce10, A. John Camm11
1Department of Cardiology, KardiyoRitm Cardiac Health Center, İzmir, Turkey
2Department of Cardiology, Koşuyolu Training and Research Hospital, İstanbul, Turkey
3Department of Cardiology, Katip Çelebi University Faculty of Medicine, İzmir, Turkey
4Department of Cardiology, Bursa Training and Research Hospital, Bursa, Turkey
5Department of Cardiology, Ankara Başkent University Faculty of Medicine, Ankara, Turkey
6Department of Cardiology, Marmara University Faculty of Medicine, İstanbul, Turkey
7Department of Cardiology, Medeniyet University Faculty of Medicine, İstanbul, Turkey
8Department of Cardiology, Tepecik Training and Research Hospital, İzmir, Turkey
9Department of Cardiology, Ege University Faculty of Medicine, İzmir, Turkey
10Department of Cardiology, Çiğli Regional Training Hospital, İzmir, Turkey
11St George’s University of London, United Kingdom


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 fibrillation (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 define 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.

Keywords: Atrial fibrillation, non-vitamin K antagonist oral anticoagulant, real life

How to cite this article
Uğur Önsel Türk, Rezzan Deniz Acar, Taylan Akgün, Volkan Emren, Selçuk Kanat, Emir Karacağlar, Alper Kepez, Şeref Kul, Erdem Özel, Evrim Şimşek, Selcen Yakar Tülüce, Kamil Tülüce, A. John Camm. Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases. Turk Kardiyol Dern Ars. 2020; 48(3): 289-303

Corresponding Author: Uğur Önsel Türk, Türkiye
© Copyright 2020 Archives of the Turkish Society of Cardiology
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