Lüscher Thomas F, Davies Allan, Beer Juerg H, Valgimigli Marco, Nienaber Christoph A, Camm John A, Baumgartner Iris, Diener Hans-Christoph, Konstantinides Stavros V
Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.
Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.
Eur Heart J. 2022 Mar 7;43(10):940-958. doi: 10.1093/eurheartj/ehab642.
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
血管内血栓形成和栓塞是导致许多发病率和死亡率高的心血管疾病的最常见事件。潜在原因是循环血液淤滞、遗传和后天性凝血障碍以及血管壁抗血栓或促血栓特性降低（维氏三联征）。在静脉系统中，血管内血栓可导致静脉血栓形成、肺栓塞甚至外周栓塞，包括缺血性中风[通过卵圆孔未闭（PFO）]。左心房及其附件或心室中的血栓分别在房颤和梗死的情况下形成。此外，血栓可在天然或人工主动脉瓣上、主动脉内（特别是溃疡、主动脉夹层和腹主动脉瘤部位）以及脑动脉和外周动脉中形成，分别导致中风和肢体严重缺血。最后，供应心脏、大脑、肾脏和四肢等重要器官的动脉可能发生血栓闭塞。血栓形成和栓塞可根据其形成和栓塞的部位以及患者特征，使用抗凝剂和器械进行处理。机械瓣膜患者首选维生素K拮抗剂，而新型口服抗凝剂是大多数其他心血管疾病的首选，特别是静脉血栓栓塞和房颤。由于抗凝剂有出血风险，对于出血风险增加的患者，首选如PFO封堵器或左心耳封堵器等器械。阿司匹林和/或P2Y12拮抗剂等血小板抑制剂在冠心病、中风和外周动脉疾病的二级预防中，根据临床情况单独或联合使用时是首选。本文推荐并综述了抗凝剂、血小板抑制剂和器械的差异化和个性化使用。
