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    Coronary artery disease in outpatients with nonvalvular atrial fibrillation: results from the multicenter RAMSES study
    (LIPPINCOTT WILLIAMS & WILKINS, 2016) Dogan, Volkan; Basaran, Ozcan; Beton, Osman; Tekinalp, Mehmet; Bolat, Ismail; Kalaycioglu, Ezgi; Aykan, Ahmet Cagri; Tasar, Onur; Safak, Ozgen; Kalcik, Macit; Yaman, Mehmet; Kirma, Cevat; Biteker, Murat
    Background Nonvalvular atrial fibrillation (NVAF) frequently coexists with coronary artery disease (CAD). However, the optimal antithrombotic strategy for patients with concomitant CAD and NVAF is controversial. The aim of this study is to assess the prevalence of CAD with NVAF and to determine antithrombotic treatment options in patients with or without a history of CAD. Methods ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey (RAMSES study) was a cross-sectional, multicenter, nationwide observational study carried out in NVAF patients. We studied the clinical data of 6264 Turkish patients participating in the RAMSES study. Demographic properties and antithrombotic therapies were recorded and compared between patients with and without CAD. Results CAD was present in 1828 (29.2%) of patients with NVAF. Most of the NVAF patients with CAD were men (58%) and comorbid diseases were significantly more common in patients with CAD. Although patients with CAD had higher CHA(2)DS(2)VASc scores than those without disease (4.1 +/- 1.5 vs. 2.9 +/- 1.5; P=0.001), they had lower use of oral anticoagulant (OAC) therapy (66.1 vs. 74.4%, P=0.01). Among OAC drugs, warfarin was the preferred medication in patients with CAD (35.4 vs. 30.6%, P=0.01), whereas nonvitamin K antagonist oral anticoagulants were preferred in patients without CAD (40 vs. 34.3%, P=0.01). Patients with CAD required nearly three-fold higher antiplatelet treatment compared with patients without CAD (57.8 vs. 21.4%, P<0.001). Conclusion CAD affects nearly one-third of patients with NVAF in a real-world setting. Although they merit more aggressive therapy, patients with CAD and NVAF were less likely to receive OAC therapy. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.
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    Drug Adherence in Patients With Nonvalvular Atrial Fibrillation Taking Non-Vitamin K Antagonist Oral Anticoagulants in Turkey: NOAC-TR
    (SAGE PUBLICATIONS INC, 2018) Emren, Sadik Volkan; Senoz, Oktay; Bilgin, Murat; Beton, Osman; Aslan, Abdullah; Taskin, Ugur; Aciksari, Gonul; Asarcikli, Lale Dinc; Cakir, Hakan; Bekar, Lutfu; Bolat, Ismail; Yayla, Cagri; Celebi, Baris; Dalgic, Onur; Celik, Oguzhan; Safak, Ozgen; Akyel, Serdar; Gungor, Hasan; Duzel, Baris; Zoghi, Mehdi
    Adherence to non-vitamin K antagonist oral anticoagulants (NOACs) is an important factor for ensuring efficacy and safety in nonvalvular atrial fibrillation (NVAF). There are controversial results regarding NOAC adherence in real-world data and there are no data about NOAC adherence in Turkish population. This study investigated the NOAC adherence based on self-report, factors affecting nonadherence, and the relation of the adherence level with efficacy and safety outcomes. This multicenter cross-sectional study included 2738 patients (59% female) using NOAC (dabigatran, apixaban, and rivaroxaban) due to NVAF for more than 3 months with >30 days of supply between September 1, 2015, and February 28, 2016. To measure the adherence level, an 8-item Morisky Medication Adherence Scale was used. The mean age of the patients was 70 +/- 10 years. Of the 2738 patients, 44% were receiving dabigatran, 38% rivaroxaban, and 18% apixaban. A total of 630 (23%) patients had high medication adherence, 712 (26%) moderate adherence, and 1396 (51%) low adherence. Nonadherence had related to stroke (5.6% vs 2.5%, P < .001) and minor (21.2% vs 11.1%, P < .001) and major (6.1% vs 3.7%, P = .004) bleeding rates. The adherence to NOAC was found to be quite low in Turkey. Nonadherence is associated with bleeding and thromboembolic cardiovascular events. Age, taking NOAC twice a day, and the additional noncardiac diseases, depression, and dementia were the independent factors affecting poor medication adherence.
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    Gender-related differences in presentation and treatment of patients with non-valvular atrial fibrillation: results from RAMSES study
    (TURKISH SOC CARDIOLOGY, 2017) Dogan, Volkan; Basaran, Ozcan; Beton, Osman; Tekinalp, Mehmet; Aykan, Ahmet Cagri; Kalaycioglu, Ezgi; Bolat, Ismail; Tasar, Onur; Safak, Ozgen; Kalcik, Macit; Kirma, Cevat; Biteker, Murat
    Objective: Gender is an important feature in the management of atrial fibrillation (AF). This study investigated gender-related differences in patients with AF in Turkey. Methods: As a part of RAMSES (ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in Turkey, NCT02344901) study, information of the patients with AF who successively applied to the hospital was analyzed. This cross-sectional, multi-center, nationwide observational study enrolled 6264 non-valvular AF (NVAF) outpatients (55.9% women) from Turkey. Results: Compared with men, women with NVAF were older (71 years [range: 65-78 years] vs. 70 years [range: 62-77 years]; p<0.001), had lower frequency of coronary artery disease (22.0% vs. 38.3%; p<0.001) and congestive heart failure (18.2% vs. 27.2%; p<0.001). Women had higher median CHA(2)DS(2)-VASc score (4 [range: 3-5] vs. 3 [range: 2-4]; p<0.001), but similar HAS-BLED score (2 [range: 1-2] vs. 2 [range: 1-2]; p=0.141) when compared with men. Anticoagulant therapy use was higher in women (74.5% vs. 69.9%; p<0.001). Analysis of anticoagulation therapy use revealed that 68.5% of men and 61.6% of women (p=0.204) who had low risk for stroke (CHA(2)DS(2)-VASc score: 0 [male], 1 [female]) received anticoagulation therapy, and 30.5% of the men. Meanwhile, 25.3% of the women (p<0.001) with high risk for stroke (CHA(2)DS(2)-VASc score: >= 1 [male], >= 2 [female]) had not received any anticogulant therapy. Conclusion: Although women with NVAF receive better treatment than men, anticoagulation therapy is suboptimal in large proportion of men and women, with underuse in high-risk patients and overuse in low-risk patients. There is an urgent need to improve optimization of anticoagulation in patients with NVAF.
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    Impact of valvular heart disease on oral anticoagulant therapy in non-valvular atrial fibrillation: results from the RAMSES study
    (SPRINGER, 2017) Basaran, Ozcan; Dogan, Volkan; Beton, Osman; Tekinalp, Mehmet; Aykan, Ahmet Cagri; Kalaycioglu, Ezgi; Bolat, Ismail; Tasar, Onur; Safak, Ozgen; Kalcik, Macit; Yaman, Mehmet; Inci, Sinan; Altintas, Bernas; Kalkan, Sedat; Kirma, Cevat; Biteker, Murat
    The definition of non-valvular atrial fibrillation (NVAF) is controversial. We aimed to assess the impact of valvular heart disease on stroke prevention strategies in NVAF patients. The RAMSES study was a multicenter and cross-sectional study conducted on NVAF patients (ClinicalTrials.gov identifier NCT02344901). The study population was divided into patients with significant valvular disease (SVD) and non-significant valvular disease (NSVD), whether they had at least one moderate valvular disease or not. Patients with a mechanical prosthetic valve and mitral stenosis were excluded. Baseline characteristics and oral anticoagulant (OAC) therapies were compared. In 5987 patients with NVAF, there were 3929 (66%) NSVD and 2058 (34%) SVD patients. The predominant valvular disease was mitral regurgitation (58.1%), followed by aortic regurgitation (24.1%) and aortic stenosis (17.8%). Patients with SVD had higher CHA(2)DS(2)VASc [3.0 (2.0; 4.0) vs. 4.0 (2.0; 5.0), p < 0.001] and HAS-BLED [2.0 (1.0; 2.0) vs. 2.0 (1.0; 2.0), p = 0.004] scores compared to patients with NSVD. Overall, 2763 (71.2%) of NSVD and 1515 (73.8%) of SVD patients were on OAC therapy (p = 0.035). When the patients with SVD were analyzed separately, the mean CHA(2)DS(2)VASc and HAS-BLED scores were higher in patients with mitral regurgitation compared to patients with aortic regurgitation and aortic stenosis [4.0 (3.0; 5.0), 3.0 (2.0; 4.0), 3.0 (2.0; 4.0) p < 0.001 and 2.0 (1.0; 3.0), 1.0 (1.0; 2.0), 1.0 (0.0; 2.0) p < 0.001, respectively]. In patients with SVD, 65.7% of mitral regurgitation, 82.6% of aortic regurgitation and 88.0% of aortic stenosis patients were on OAC therapy. One out of three NVAF patients had at least one moderate valvular heart disease with the predominance of mitral regurgitation. Patients with SVD were at greater risk of stroke and bleeding compared to patients with NSVD. Although patients with mitral regurgitation should be given more aggressive anticoagulant therapy due to their higher risk of stroke, they are undertreated compared to patients with aortic valve diseases.
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    Real-world stroke prevention strategies in nonvalvular atrial fibrillation in patients with renal impairment
    (WILEY, 2017) Mert, Kadir U.; Mert, Gurbet O.; Basaran, Ozcan; Beton, Osman; Dogan, Volkan; Tekinalp, Mehmet; Aykan, Ahmet C.; Kalaycioglu, Ezgi; Bolat, Ismail; Tasar, Onur; Safak, Ozgen; Kalcik, Macit; Yaman, Mehmet; Kirma, Cevat; Biteker, Murat
    BackgroundThe data regarding stroke prevention strategies in nonvalvular atrial fibrillation (NVAF) are limited especially in patients with renal impairment (RI). We sought to evaluate management dilemmas in patients with concurrent NVAF and RI in RAMSES (ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies inTurkey) study. MethodsWe conducted a prospective, multicenter, nation-wide registry in NVAF patients in outpatient cardiology clinics. All consecutive patients with NVAF were enrolled in RAMSES study (ClinicalTrials.gov identifier NCT02344901). The baseline data were collected. Glomerular filtration rate (GFR) was estimated by Cockcroft-Gault equation. ResultsA total number of 6273 patients from 29 provinces of Turkey with the contribution of 83 investigators were enrolled to the study. Of the study population, 1964(33%) patients had RI which was defined as GFR < 60 mL/min. Patients with RI had significantly higher CHA(2)DS(2)VASc and HAS-BLED scores compared to those without RI (39 15 vs. 29 +/- 15, and 20 +/- 1 vs. 14 +/- 1; P < 0001). Prior history of major bleeding (69% vs. 41%, P < 0001) and stroke (162% vs. 118%, P < 0001) was significantly higher among individuals with concomitant RI and NVAF. Although RI patients had a higher risk for thromboembolism, number of the patients who did not receive any anticoagulant therapy was higher in patients with RI than without RI (301 vs. 264%, P = 0003). ConclusionRAMSES study showed that one-third of the patients with NVAF had RI in the real-world setting. Although it is mandatory in most of the patients with concomitant NVAF and RI, nearly one-third of these patients did not receive any anticoagulant therapy.
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    Suboptimal use of non-vitamin K antagonist oral anticoagulants: Results from the RAMSES study
    (LIPPINCOTT WILLIAMS & WILKINS, 2016) Basaran, Ozcan; Dogan, Volkan; Beton, Osman; Tekinalp, Mehmet; Aykan, Ahmet Cagri; Kalaycioglu, Ezgi; Bolat, Ismail; Tasar, Onur; Safak, Ozgen; Kalcik, Macit; Yaman, Mehmet; Inci, Sinan; Altintas, Bernas; Kalkan, Sedat; Kirma, Cevat; Biteker, Murat; Karadeniz, Fatma Ozpamuk; Tekkesin, Ahmet Ilker; Cakilli, Yasin; Turkkan, Ceyhan; Hamidi, Mehmet; Demir, Vahit; Gursoy, Mustafa Ozan; Ozturk, Mujgan Tek; Aksan, Gokhan; Seyis, Sabri; Balli, Mehmet; Alici, Mehmet Hayri; Bozyel, Serdar; Altun, Ibrahim; Calik, Feyza; Karaca, Oguz; Helvaci, Fusun; Akay, Kadriye; Canga, Yigit; Celebi, Savas; Altuntas, Emine; Ayturk, Mehmet; Gunes, Haci Murat; Bezgin, Tahir; Aksakal, Aytekin; Cakal, Beytullah; Colak, Ayse; Kaplan, Ozgur; Tatlisu, Adem; Gozubuyuk, Gokhan; Demirelli, Selami; Kaya, Adnan; Rencuzogullari, Ibrahim; Bayram, Zubeyde; Simsek, Zeki; Civan, Murat; Batgharel, Ulaankhu; Ata, Ali Ekber; Gol, Gokhan; Mert, Gurbet Ozge; Mert, Kadir Ugur; Degirmencioglu, Aleks; Candan, Ozkan; Celebi, Ozlem Ozcan; Dogan, Cem; Yavuz, Fethi; Ulucan, Seref; Arisoy, Arif; Sahin, Bingul Dilekci; Ermis, Emrah; Gokaslan, Serkan; Pektas, Idris; Tanindi, Asli; Tekin, Kamuran; Sancar, Kadriye Memic; Cekic, Edip Guvenc; Basaran, Nesrin Filiz
    This study aimed to investigate the potential misuse of novel oral anticoagulants (NOACs) and the physicians' adherence to current European guideline recommendations in real-world using a large dataset from Real-life Multicenter Survey Evaluating Stroke Prevention Strategies in Turkey (RAMSES Study).RAMSES study is a prospective, multicenter, nationwide registry (ClinicalTrials.gov identifier NCT02344901). In this subgroup analysis of RAMSES study, patients who were on NOACs were classified as appropriately treated (AT), undertreated (UT), and overtreated (OT) according to the European Society of Cardiology (ESC) guidelines. The independent predictors of UT and OT were determined by multivariate logistic regression.Of the 2086 eligible patients, 1247 (59.8%) received adequate treatment. However, off-label use was detected in 839 (40.2%) patients; 634 (30.4%) patients received UT and 205 (9.8%) received OT. Independent predictors of UT included >65 years of age, creatinine clearance 50mL/min, urban living, existing dabigatran treatment, and HAS-BLED score of <3, whereas that of OT were creatinine clearance <50mL/min, ongoing rivaroxaban treatment, and HAS-BLED score of 3.The suboptimal use of NOACs is common because of physicians' poor compliance to the guideline recommendations in patients with nonvalvular atrial fibrillation (NVAF). Older patients who were on dabigatran treatment with good renal functions and low risk of bleeding were at risk of UT, whereas patients who were on rivaroxaban treatment with renal impairment and high risk of bleeding were at risk of OT. Therefore, a greater emphasis should be given to prescribe the recommended dose for the specified patients.
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    The effect of adding wheat and corn gluten to the diet of rats on the autoimmune and histopathological parameters in the intestine and liver
    (Univ Zulia, Facultad Ciencias Veterinarias, 2024) Gumus, Recep; Kapakin, Kubra Asena Terim; Kirman, Esra Manavoglu; Bolat, Ismail; Imik, Aybuke; Ercan, Nazli
    This study investigated the histopathological and immunohistochemical effect on the intestine and liver tissues with addition of the soybean meal (SBM), wheat Gluten meal (WGM) and Corn gluten meal (CGM) to rat diet. A total of 24 average twenty-day-old male rats (Wistar albino) were used in the study. The rats were randomly divided into 3 groups with 8 animals in each group (Control, Wheat and Corn groups). The diet provided to all three groups contained proteins, which were SBM, WGM and CGM in the Control, Wheat and Corn groups, respectively. In the study, the group fed with SBM was used as the Control group. Rats were fed a diet containing 22% crude protein and 2,598 kcalkg(-1) metabolic energy throughout the experimental period. The feeding trial was continued for a period of 50 days. Degenerative changes of varying severity in intestinal epithelial cells and atrophy in villi were observed. Similarly, the degenerative changes, especially vacuolar or hydropic degeneration were determined in hepatocytes. It was determined that the CD4 level were statistically significantly increased in the Wheat and Corn groups compared to the Control group ( P <0.01) on intestine tissue. Also, it was determined that the IgA level was statistically significantly increased of the Wheat and Corn groups in liver tissue. ( P <0.05). As a result, it was observed that the histopathological and immunohistochemical parameters of the intestine and liver tissues of the rats fed with diets containing highly WGM and CGM were limitedly affected.