tianjin medical university.
Cardiol J. 2018;25(5):611-620. doi: 10.5603/CJ.a2017.0112. Epub 2017 Oct 5.
Inhibition of the renin-angiotensin axis can reduce the likelihood of atrial fibrillation (AF). However, the effects of angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on thrombogenicity in AF remain incompletely elucidated. Thisretrospective case-control study was conducted to evaluate whether the use of ACEI or ARB could reduce the incidence of left atrial appendage thrombus (LAAT) and spontaneous echocardiographic contrast (SEC) in patients with AF.
A total of 199 AF patients who received both transesophageal echocardiogram (TEE) and transthoracic echocardiogram (TTE) successively on the same day from 2012 to 2016 were enrolled. Left atrial dimension, maximal left atrial volume (LAVmax), left ventricular end-diastolic dimension, left ventricular ejection fraction, and the ratio of the early transmitral flow velocity and the early mitral annular velocity (E/e') were determined. Longitudinal LA strain was evaluated using two-dimensional speckle tracking imaging at each LA segment. Peak systolic strain was calculated by averaging total segments. LAAT, LAA emptying flow velocity (LAAeV) and SEC were evaluated by TEE. Risk factors for LAAT and usage of ACEIs or ARBs were recorded.
The incidence of LAAT was 27.6%. Among the patients with renin-angiotensin system (RAS) inhibitors, 20.5% were demonstrated to have LAAT, compared with 33.3% in the nonuser group (p = 0.044). LA peak systolic strain and LAAeV were significantly increased in patients with RAS inhibitors compared to the nonuser group (p = 0.002, p = 0.047, respectively). Patients with LAAT had higher CHA2DS2-VASc scores and evident SEC compared with those without LAAT (p = 0.000, p = 0.000, respectively). Usage of ACEIs/ARBs and antiplatelet drugs were frequent in patients with LAAT than in those without LAAT (p = 0.044, p = 0.000, respectively). Even after controlling for LAAT-related risk factors (age, body mass index, AF type, hypertension, diabetes mellitus, prior stroke or transient ischemic attack, drinking history and usage of antiplatelet drugs and LAVmax), use of RAS inhibitors remained significantly associated with a lower risk of LAAT (OR = 0.222; 95% CI 0.084-0.585, p = 0.002).
This study shows that RAS inhibitors may be effective in reducing the risk of LAAT in patients with AF through atrial reverse remodeling.
抑制肾素-血管紧张素轴可以降低心房颤动（AF）的可能性。然而，血管紧张素转换酶抑制剂（ACEI）或血管紧张素 II 受体阻滞剂（ARB）对 AF 中血栓形成的影响仍不完全清楚。这项回顾性病例对照研究旨在评估 ACEI 或 ARB 的使用是否可以降低 AF 患者左心耳血栓（LAAT）和自发性超声对比（SEC）的发生率。
2012 年至 2016 年期间，共纳入 199 名 AF 患者，这些患者在同一天先后接受经食管超声心动图（TEE）和经胸超声心动图（TTE）检查。测量左心房内径、最大左心房容积（LAVmax）、左心室舒张末期内径、左心室射血分数以及二尖瓣前向血流速度与二尖瓣环早期运动速度的比值（E/e'）。使用二维斑点追踪成像在每个左心房节段评估左心房纵向应变。通过平均总节段计算收缩期峰值应变。使用 TEE 评估 LAAT、左心耳排空流速（LAAeV）和 SEC。记录 LAAT 的危险因素和 ACEI 或 ARB 的使用情况。
LAAT 的发生率为 27.6%。在使用肾素-血管紧张素系统（RAS）抑制剂的患者中，有 20.5%的患者出现 LAAT，而非使用者组为 33.3%（p = 0.044）。与非使用者组相比，使用 RAS 抑制剂的患者 LA 收缩期峰值应变和 LAAeV 明显增加（p = 0.002，p = 0.047）。与无 LAAT 的患者相比，有 LAAT 的患者 CHA2DS2-VASc 评分更高，且 SEC 明显（p = 0.000，p = 0.000）。与无 LAAT 的患者相比，有 LAAT 的患者更常使用 ACEI/ARB 和抗血小板药物（p = 0.044，p = 0.000）。即使控制了与 LAAT 相关的危险因素（年龄、体重指数、AF 类型、高血压、糖尿病、既往卒中和短暂性脑缺血发作、饮酒史以及抗血小板药物和 LAVmax 的使用），RAS 抑制剂的使用与 LAAT 的风险降低显著相关（OR = 0.222；95%CI 0.084-0.585，p = 0.002）。
这项研究表明，RAS 抑制剂通过心房逆向重构可能有效降低 AF 患者 LAAT 的风险。
