School of Medicine, University of Leeds, Leeds, UK.
Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
ESC Heart Fail. 2020 Oct;7(5):2032-2041. doi: 10.1002/ehf2.12718. Epub 2020 Jun 25.
Left ventricular (LV) thrombus is increasingly detected in patients with and without ischaemic heart disease due to the increased availability of cardiac magnetic resonance imaging. Risk factors include anterior ST elevation myocardial infarction, delayed reperfusion therapy, and non-ischaemic cardiomyopathy with severe LV systolic dysfunction. We aimed to report the characteristics and outcomes of patients with LV thrombus treated with either vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC) with a view to describing differences in efficacy, specifically, subsequent thromboembolic events, thrombus resolution, and also side effects of therapy including clinically significant bleeding.
We conducted a retrospective, observational cohort study of patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018 and treated with either DOAC or VKA. We recorded patient demographics, past medical history, prescribed medications, and baseline investigations. The primary outcomes were rates of thromboembolism and clinically significant bleeding, with secondary outcomes of thrombus resolution on repeat cardiac imaging, repeat hospitalization, and all-cause mortality. During the study period, 84 patients were diagnosed with and managed for LV thrombus. Of these, 62 received VKA and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran. Most patients 75 (89%) were male with an average age of 62 ± 14 years. Ischaemic heart disease was the cause of LV impairment in 73 (87%) patients. Baseline characteristics were similar between groups at baseline. Most n = 55 (65%) were co-prescribed a single antiplatelet agent and 32 (38%) received dual-antiplatelet therapy. During an average follow-up of 3.0 ± 1.4 years, there were no statistically significant differences between VKA and DOAC in rates of stroke (2% vs. 0%, P = 0.55), other thromboemboli (2% vs. 0%, P = 0.55), or clinically significant bleeding (10% vs. 0%, P = 0.13). The average interval to cardiac imaging follow-up was 233 ± 251 days and was not different between groups (P = 0.83), and there was no difference in the rate of resolution of thrombus (76% vs. 65% P = 0.33). Rehospitalization (50% vs. 45%: P = 0.53) and all-cause mortality (10% vs. 14%; P = 0.61) were also similar.
Our data suggest that DOACs are likely to be at least as effective and safe as VKA for stroke prevention in patients with LV thrombus and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting. The optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high-risk patients, should be tested in prospective, randomized trials.
由于心脏磁共振成像的广泛应用，越来越多的患有缺血性心脏病和无缺血性心脏病的患者被检测出左心室（LV）血栓。危险因素包括前壁 ST 段抬高型心肌梗死、延迟再灌注治疗和伴有严重 LV 收缩功能障碍的非缺血性心肌病。我们旨在报告接受维生素 K 拮抗剂（VKA）或直接口服抗凝剂（DOAC）治疗的 LV 血栓患者的特征和结局，以期描述疗效、特别是随后的血栓栓塞事件、血栓溶解以及治疗相关副作用（包括临床上显著的出血）方面的差异。
我们对 2012 年 12 月 1 日至 2018 年 6 月 30 日期间诊断为 LV 血栓并接受 DOAC 或 VKA 治疗的患者进行了回顾性、观察性队列研究。我们记录了患者的人口统计学、既往病史、处方药物和基线检查。主要结局为血栓栓塞和临床上显著出血的发生率，次要结局为重复心脏成像、重复住院和全因死亡率的血栓溶解情况。在研究期间，共诊断出 84 例 LV 血栓并进行了管理。其中 62 例接受 VKA 治疗，22 例接受 DOAC 治疗，包括 13 例利伐沙班、8 例阿哌沙班和 1 例达比加群。大多数患者（75 例，89%）为男性，平均年龄为 62±14 岁。73 例（87%）患者的 LV 损伤是由缺血性心脏病引起的。两组患者的基线特征相似。大多数患者（n=55，65%）同时服用一种抗血小板药物，32 例（38%）接受双联抗血小板治疗。在平均 3.0±1.4 年的随访期间，VKA 和 DOAC 组在卒中（2% vs. 0%，P=0.55）、其他血栓栓塞（2% vs. 0%，P=0.55）或临床上显著出血（10% vs. 0%，P=0.13）方面的发生率无统计学差异。平均心脏成像随访时间为 233±251 天，两组间无差异（P=0.83），血栓溶解率也无差异（76% vs. 65%，P=0.33）。再住院率（50% vs. 45%：P=0.53）和全因死亡率（10% vs. 14%；P=0.61）也相似。
我们的数据表明，DOAC 可能至少与 VKA 一样有效和安全，可预防 LV 血栓患者发生卒中，并且尽管它们没有用于该适应证的许可，但对于这种情况，它们可能是一种合理且更方便的选择。LV 血栓的最佳抗凝时机和类型，以及筛查高危患者的作用，应在前瞻性、随机试验中进行检验。
