Blood Stasis Secondary to Heart Failure Forms Warfarin-Resistant Left Atrial Thrombus
Blood Stasis Secondary to Heart Failure Forms Warfarin-Resistant Left Atrial Thrombus
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DOI：
10.1536/ihj.14-133
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发表时间：
2014-11-01
影响因子：
1.5
通讯作者：
Yamashita, Takeshi
中科院分区：
文献类型：
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作者：
Watanabe, Atai;Yamashita, Naohide;Yamashita, Takeshi
对于房颤(AF)患者，建议使用华法林等抗凝药物，以降低与左房血栓形成相关的中风风险。然而，在一组患者中，华法林在治疗剂量下无法防止LA血栓形成。本研究描述了华法林抵抗的左房血栓患者的临床和超声心动图特征。在1364名接受经食道超声心动图检查的非瓣膜性房颤患者中，431人接受了华法林治疗。总共有10名患者(2.3%的接受华法林治疗的患者)即使在华法林治疗期间也出现了左房血栓形成，剂量和持续时间足以将凝血酶原时间国际标准化比率(PT-INR)提高到治疗范围>；=30天。分类回归分析显示，左心耳(LAA)血流速度降低、左房自发超声心动图对比度(LASEC)增大、左室射血分数(LVEF)降低是左房残余血栓形成的重要因素(均P<；0.05)。受试者工作特征(ROC)曲线分析表明，较高的右室收缩压(曲线下面积为0.85)、LV质量指数(0.81)和LA内径(0.68)，以及较低的LAA血流速度(0.92)和LVEF(0.91)预示着华法林抵抗的LA血栓的形成(P均<0.05)。这些结果表明，心力衰竭继发于血瘀证是华法林抵抗的LA血栓形成的原因。我们建议，对于心力衰竭的房颤患者，增加LVEF的治疗应该与华法林一起使用，以降低卒中风险。
Anticoagulants such as warfarin are recommended for patients with atrial fibrillation (AF) to decrease stroke risk associated with thrombus formation in the left atrium (LA). In a subgroup of patients, however, warfarin is unable to prevent LA thrombus formation at therapeutic doses. This study characterized the clinical and echocardiographic features of patients having warfarin-resistant LA thrombus.Of the 1364 nonvalvular AF patients examined by transesophageal echocardiography, 431 received warfarin. A total of 10 patients (2.3% of warfarin-treated patients) exhibited LA thrombus formation even during warfarin treatment at a dose and duration sufficient for increasing the prothrombin time international normalized ratio (PT-INR) to the therapeutic range for >= 30 days. Categorical regression analysis revealed that decreased LA appendage (LAA) flow velocity, greater LA spontaneous echocardiographic contrast (LASEC), and lower left ventricular ejection fraction (LVEF) significantly contributed to residual LA thrombus (P < 0.05 for all). Receiver operating characteristic (ROC) curve analysis indicated that higher right ventricular systolic pressure, which suggests LA pressure (area under curve, 0.85), LV mass index (0.81), and LA dimension (0.68), as well as lower LAA flow velocity (0.92) and LVEF (0.91) predicted warfarin-resistant LA thrombus formation (all P < 0.05).These results suggest that blood stasis secondary to heart failure contributes to the formation of warfarin-resistant LA thrombus. We propose that therapies to increase LVEF should be administered together with warfarin for AF patients with heart failure to decrease stroke risk.