Michael Faith, Natt Navneet, Shurrab Mohammed
Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada.
Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada.
CJC Open. 2021 May 6;3(9):1169-1181. doi: 10.1016/j.cjco.2021.04.007. eCollection 2021 Sep.
There is increasing interest in direct oral anticoagulants (DOACs), given their safety and convenience in atrial fibrillation, compared with vitamin K antagonists (VKAs). However, the use of DOACs in left ventricular (LV) thrombi is considered off-label, with current guidelines recommending VKAs. The aim of this meta-analysis was to compare the safety and efficacy of DOACs to VKAs in the management of LV thrombi.
A systematic search was conducted for studies published between January 1, 2009 and January 31, 2021 in PubMed, Embase, and CENTRAL. Included studies compared DOACs to VKAs for the treatment of LV thrombi and reported on relevant outcomes. Odds ratios (ORs) were pooled with a random-effects model.
Sixteen cohort studies and 2 randomized controlled trials were identified, which included 2666 patients (DOAC = 674; VKA = 1992). Compared with VKAs, DOACs were associated with a statistically significant reduction in stroke (OR 0.63, 95% confidence interval [CI] 0.42-0.96; = 0.03; = 0%). There were no significant differences in bleeding (OR 0.72, 95% CI 0.50-1.02; = 0.07; = 0%), systemic embolism (OR 0.77, 95% CI 0.41-1.44; = 0.41; = 0%), stroke or systemic embolism (OR 0.83, 95% CI 0.53-1.33; = 0.45; = 33%), mortality (OR 1.01, 95% CI 0.64-1.57; = 0.98; = 0%) or LV thrombus resolution (OR 1.29, 95% CI 0.83-1.99; = 0.26; = 56%).
Within the context of low-quality evidence, there was a statistically significant reduction in stroke among those treated with DOACs, without an increase in bleeding. There were no significant differences in systemic embolism, stroke or systemic embolism, mortality, or LV thrombus resolution, suggesting that DOACs may be a reasonable option for treatment of LV thrombi.
与维生素K拮抗剂（VKA）相比，直接口服抗凝剂（DOAC）因其在房颤治疗中的安全性和便利性而受到越来越多的关注。然而，DOAC在左心室（LV）血栓治疗中的应用被认为是超说明书用药，目前指南推荐使用VKA。本荟萃分析的目的是比较DOAC与VKA在治疗LV血栓方面的安全性和有效性。
对2009年1月1日至2021年1月31日期间发表在PubMed、Embase和CENTRAL上的研究进行系统检索。纳入的研究比较了DOAC与VKA治疗LV血栓的效果，并报告了相关结果。采用随机效应模型汇总比值比（OR）。
共纳入16项队列研究和2项随机对照试验，包括2666例患者（DOAC组=674例；VKA组=1992例）。与VKA相比，DOAC治疗组的卒中发生率有统计学意义的显著降低（OR 0.63，95%置信区间[CI]0.42-0.96；P=0.03；I²=0%）。出血（OR 0.72，95%CI 0.50-1.02；P=0.07；I²=0%）、全身性栓塞（OR 0.77，95%CI 0.41-1.44；P=0.41；I²=0%）、卒中或全身性栓塞（OR 0.83，95%CI 0.53-1.33；P=0.45；I²=33%）、死亡率（OR 1.01，95%CI 0.64-1.57；P=0.98；I²=0%）或LV血栓溶解（OR 1.29，95%CI 0.83-1.99；P=0.26；I²=56%）方面均无显著差异。
在低质量证据的背景下，DOAC治疗组的卒中发生率有统计学意义的显著降低，且出血未增加。在全身性栓塞、卒中或全身性栓塞、死亡率或LV血栓溶解方面无显著差异，这表明DOAC可能是治疗LV血栓的合理选择。
