Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus
Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus
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DOI：
10.1016/j.jacc.2020.01.057
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发表时间：
2020-04-14
影响因子：
24
通讯作者：
Silvain, Johanne
中科院分区：
文献类型：
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作者：
Lattuca, Benoit;Bouziri, Nesrine;Silvain, Johanne
背景目前缺乏关于左心室血栓（LVT）的预后和管理的数据。结论本研究的目的是使用序贯成像量化抗凝治疗对LVT演变的影响，并确定LVT消退对血栓栓塞、出血和死亡率的影响。方法从2011年1月至2018年1月，使用90，065份连续超声心动图报告进行LVT的全面计算机检索。只有确诊LVT的患者在2名独立专家进行影像学审查后才被纳入。主要不良心血管事件（MACE），其中包括死亡，中风，心肌梗死，或急性外周动脉栓塞，以及大出血事件（BARC >= 3）和全因死亡率进行了测定。患者接受维生素K拮抗剂（48.4%）、肠外肝素（27.7%）和直接口服抗凝剂（22.6%）治疗。67.9%的人群使用抗血小板治疗。在121例患者（76.1%）中观察到LVT面积较基线减少，99例患者（62.3%）在中位时间103天（四分位距：32 - 392天）内发生总LVT消退。LVT回归的独立相关因素是非缺血性心肌病（风险比[HR]：2.74; 95%置信区间[CI]：1.43至5.26; p = 0.002）和较小的基线血栓面积（HR：0.66; 95%CI：0.45至0.96; p = 0.031）。在中位随访632天（四分位距：187 - 1,126天）期间，MACE的频率为37.1%;死亡率为18.9%;卒中为13.3%;大出血为13.2%。总LVT消退患者和持续性LVT患者的MACE发生率分别为35.4%和40.0%（p = 0.203）。在LVT完全消退的患者中观察到死亡风险降低（HR：0.48; 95% CI：0.23 - 0.98; p = 0.039），而在持续性LVT患者中观察到大出血风险增加（9.1% vs. 12%; HR 0.34; 95% CI：0.14 - 0.82; p = 0.011）。左心室射血分数>= 35%（HR：0.46; 95% CI：0.23至0.93; p = 0.029）和抗凝治疗>3个月（HR：0.42; 95% CI：0.20 - 0.88; P = 0.021）与较低的MACE独立相关。结论LVT的存在与MACE和死亡率的高风险相关。采用不同抗凝方案获得的LVT总消退与死亡率降低相关。(C)2020年由美国心脏病学会基金会。
BACKGROUND Contemporary data are lacking regarding the prognosis and management of left ventricular thrombus (LVT).OBJECTIVES The purpose of this study was to quantify the effect of anticoagulation therapy on LVT evolution using sequential imaging and to determine the impact of LVT regression on the incidence of thromboembolism, bleeding, and mortality.METHODS From January 2011 to January 2018, a comprehensive computerized search of LVT was conducted using 90,065 consecutive echocardiogram reports. Only patients with a confirmed LVT were included after imaging review by 2 independent experts. Major adverse cardiovascular events (MACE), which included death, stroke, myocardial infarction, or acute peripheral artery emboli, were determined as well as major bleeding events (BARC >= 3) and all-cause mortality rates.RESULTS There were 159 patients with a confirmed LVT. Patients were treated with vitamin K antagonists (48.4%), parenteral heparins (27.7%), and direct oral anticoagulants (22.6%). Antiplatelet therapy was used in 67.9% of the population. A reduction of the LVT area from baseline was observed in 121 patients (76.1%), and total LVT regression occurred in 99 patients (62.3%) within a median time of 103 days (interquartile range: 32 to 392 days). The independent correlates of LVT regression were a nonischemic cardiomyopathy (hazard ratio [HR]: 2.74; 95% confidence interval [CI]: 1.43 to 5.26; p = 0.002) and a smaller baseline thrombus area (HR: 0.66; 95% CI: 0.45 to 0.96; p = 0.031). The frequency of MACE was 37.1%; mortality 18.9%; stroke 13.3%; and major bleeding 13.2% during a median follow-up of 632 days (interquartile range: 187 to 1,126 days). MACE occurred in 35.4% and 40.0% of patients with total LVT regression and those with persistent LVT (p = 0.203). A reduced risk of mortality was observed among patients with total LVT regression (HR: 0.48; 95% CI: 0.23 to 0.98; p = 0.039), whereas an increased major bleeding risk was observed among patients with persistent LVT (9.1% vs. 12%; HR 0.34; 95% CI: 0.14 to 0.82; p = 0.011). A left ventricular ejection fraction >= 35% (HR: 0.46; 95% CI: 0.23 to 0.93; p = 0.029) and anticoagulation therapy >3 months (HR: 0.42; 95% CI: 0.20 to 0.88; p = 0.021) were independently associated with less MACE.CONCLUSIONS The presence of LVT was associated with a very high risk of MACE and mortality. Total LVT regression, obtained with different anticoagulant regimens, was associated with reduced mortality. (C) 2020 by the American College of Cardiology Foundation.