Чистая клиническая выгода (net clinical benefit) антикоагулянтной терапии с точки зрения невролога
Чистая клиническая выгода (net clinical benefit) антикоагулянтной терапии с точки зрения невролога
Кулеш А.А. Чистая клиническая выгода (net clinical benefit) антикоагулянтной терапии с точки зрения невролога. Consilium Medicum. 2022;24(2):79–84. DOI: 10.26442/20751753.2022.2.201537
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Kulesh AA. Net clinical benefit of anticoagulant therapy from a neurologist's perspective: A review. Consilium Medicum. 2022;24(2):79–84. DOI: 10.26442/20751753.2022.2.201537
Чистая клиническая выгода (net clinical benefit) антикоагулянтной терапии с точки зрения невролога
Кулеш А.А. Чистая клиническая выгода (net clinical benefit) антикоагулянтной терапии с точки зрения невролога. Consilium Medicum. 2022;24(2):79–84. DOI: 10.26442/20751753.2022.2.201537
________________________________________________
Kulesh AA. Net clinical benefit of anticoagulant therapy from a neurologist's perspective: A review. Consilium Medicum. 2022;24(2):79–84. DOI: 10.26442/20751753.2022.2.201537
В статье применительно к инсульту рассмотрена концепция «чистой клинической выгоды» (net clinical benefit – NCB), роль прямых оральных антикоагулянтов во вторичной профилактике кардиоэмболического инсульта и NCB от их назначения. Представлены практические аспекты оценки NCB с точки зрения невролога с учетом таких факторов, как срок и тяжесть инсульта, особенности неврологического дефицита (выраженность резидуальных ограничений, дисфагия, двигательные нарушения и риск падений), нейровизуализационные характеристики инсульта (размер очага и геморрагическая трансформация) и сопутствующие неврологические заболевания (эпилепсия и деменция). Во всех указанных ситуациях применение оральных антикоагулянтов несет существенную клиническую пользу, что обосновывает недопустимость отказа в их назначении.
In this article the concept of "net clinical benefit" (NCB) is considered in the context of stroke, the role of direct oral anticoagulants in secondary prevention of cardioembolic stroke and NCB from their prescription. Practical aspects of NCB evaluation from the neurologist's point of view are presented, taking into account such factors as stroke duration and severity, features of neurological deficit (severity of residual limitations, dysphagia, motor disorders and risk of falls), neuroimaging characteristics of stroke (focal size and hemorrhagic transformation) and concomitant neurological diseases (epilepsy and dementia). In all these situations, the use of oral anticoagulants has a significant clinical benefit, which justifies the inadmissibility of refusal to prescribe them.
Keywords: stroke, atrial fibrillation, prevention, direct oral anticoagulants, net clinical benefit
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1. Seiffge DJ, Werring DJ, Paciaroni M, et al. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol. 2019;18(1):117-26.
DOI:10.1016/S1474-4422(18)30356-9
2. Hart RG, Coull BM, Hart D. Early recurrent embolism associated with nonvalvular atrial fibrillation: a retrospective study. Stroke. 1983;14(5):688-93. DOI:10.1161/01.str.14.5.688
3. Muscari A, Faccioli L, Lega MV, et al. Predicting hemorrhagic transformation and its timing from maximum cerebral lesion diameter in nonlacunar ischemic strokes. Brain Behav. 2020;10(1):e01497. DOI:10.1002/brb3.1497
4. Towse A. Net clinical benefit: the art and science of jointly estimating benefits and risks of medical treatment. Value Health. 2010;13(Suppl. 1):S30-2.
DOI:10.1111/j.1524-4733.2010.00753.x
5. Banerjee A, Lane DA, Torp-Pedersen C, Lip GY. Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a 'real world' atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost. 2012;107(3):584-9. DOI:10.1160/TH11-11-0784
6. Renda G, di Nicola M, De Caterina R. Net Clinical Benefit of Non-vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Phase III Atrial Fibrillation Trials. Am J Med.
2015;128(9):1007-14.e2. DOI:10.1016/j.amjmed.2015.03.034
7. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955-62. DOI:10.1016/S0140-6736(13)62343-0
8. Granger CB, Alexander JH, McMurray JJ, et al; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-92. DOI:10.1056/NEJMoa1107039
9. Diener HC, Hankey GJ, Easton JD, et al. Non-vitamin K oral anticoagulants for secondary stroke prevention in patients with atrial fibrillation. Eur Heart J Suppl. 2020;22(Suppl. I):I13-21. DOI:10.1093/eurheartj/suaa104
10. Proietti M, Romanazzi I, Romiti GF, et al. Real-World Use of Apixaban for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis. Stroke. 2018;49(1):98-106. DOI:10.1161/STROKEAHA.117.018395
11. Hsu JC, Hsieh CY, Yang YH, Lu CY. Net clinical benefit of oral anticoagulants: a multiple criteria decision analysis. PLoS One. 2015;10(4):e0124806. DOI:10.1371/journal.pone.0124806
12. Ntaios G, Papavasileiou V, Makaritsis K, et al. Real-World Setting Comparison of Nonvitamin-K Antagonist Oral Anticoagulants Versus Vitamin-K Antagonists for Stroke Prevention in Atrial Fibrillation: A Systematic Review and Meta-Analysis. Stroke. 2017;48(9):2494-503. DOI:10.1161/STROKEAHA.117.017549
13. Patti G, Pecen L, Lucerna M, et al. Net Clinical Benefit of Non-Vitamin K Antagonist vs Vitamin K Antagonist Anticoagulants in Elderly Patients with Atrial Fibrillation. Am J Med. 2019;132(6):749-57.e5. DOI:10.1016/j.amjmed.2018.12.036
14. Polymeris AA, Macha K, Paciaroni M, et al; NOACISP-LONGTERM, Erlangen Registry, CROMIS-2, RAF, RAF-DOAC, SAMURAI-NVAF and Verona Registry Collaborators. Oral Anticoagulants in the Oldest Old with Recent Stroke and Atrial Fibrillation. Ann Neurol. 2022;91(1):78-88. DOI:10.1002/ana.26267
15. Drogkaris S, Thomopoulos C, Kalos T, et al. Net clinical benefit of direct oral anticoagulants in atrial fibrillation patients with or without diabetes mellitus: A meta-analysis of outcome trials. Diabetes Res Clin Pract. 2021;182:109147. DOI:10.1016/j.diabres.2021.109147
16. Amin A, Keshishian A, Dina O, et al. Comparative clinical outcomes between direct oral anticoagulants and warfarin among elderly patients with non-valvular atrial fibrillation in the CMS medicare population. J Thromb Thrombolysis. 2019;48(2):240-9. DOI:10.1007/s11239-019-01838-5
17. Shah SJ, Singer DE, Fang MC, et al. Net Clinical Benefit of Oral Anticoagulation Among Older Adults With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes. 2019;12(11):e006212. DOI:10.1161/CIRCOUTCOMES.119.006212
18. Esteve-Pastor MA, Rivera-Caravaca JM, Roldán V, et al. Estimated Effectiveness and Safety of Nonvitamin K Antagonist Oral Anticoagulants Compared With Optimally Acenocoumarol Anticoagulated "Real-World" in Patients With Atrial Fibrillation. Am J Cardiol. 2018;122(5):785-92. DOI:10.1016/j.amjcard.2018.05.012
19. Zhang J, Wang X, Liu X, et al. Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis. Eur J Epidemiol. 2021;36(8):793-812. DOI:10.1007/s10654-021-00751-7
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Авторы
А.А. Кулеш*
ФГБОУ ВО «Пермский государственный медицинский университет им. акад. Е.А. Вагнера» Минздрава России, Пермь, Россия
*aleksey.kulesh@gmail.com