Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
BMJ Open Qual. 2023 Jan;12(1). doi: 10.1136/bmjoq-2022-002111.
Left ventricular (LV) thrombus is an increasingly recognised complication following anterior myocardial infarction and non-ischaemic cardiomyopathy. Whilst vitamin K antagonists (VKA) remain the only approved therapeutic option to reduce the risk of systemic thromboembolism including stroke, the off-label use of direct oral anticoagulants (DOACs) is becoming an attractive alternative.We aimed to improve the diagnosis and management of LV thrombus at a tertiary cardiology centre using quality improvement methodology. Outcomes included increasing the use of DOACs from 25% to 70% over a period of 1 year and shorten length of time from diagnosis to repeat imaging to within 3-6 months as recommended by guidelines.During the first Plan-Do-Study-Action (PDSA) cycle, we identified 84 patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018. The majority (74%) were prescribed VKA. Repeat imaging occurred in 89% of patients, but only 55% using the same modality. The mean duration between diagnosis and repeat imaging was 233±251 days. There were no significant differences between VKA and DOAC in terms of thrombus resolution, systemic embolisation or clinically significant bleeding. We published trust-wide guidelines on the management of LV thrombus with recommendations supporting the use of DOACs and appropriate follow-up imaging. A second PDSA cycle undertaken between 1 October 2019 and 31 March 2020 identified a further 20 patients. DOAC use increased to 70% and 70% of patients underwent follow-up imaging following a mean duration of 140±61 days, although in only 36% using the same modality.Using quality improvement methodology, we confirmed safe and efficient use of DOAC in the setting of LV thrombus. We published trust guidelines supporting their use, which was associated with an increase in DOAC use and in earlier follow-up imaging in line with our recommendations.
左心室 (LV) 血栓是急性前壁心肌梗死和非缺血性心肌病后越来越被认识到的并发症。虽然维生素 K 拮抗剂 (VKA) 仍然是降低包括中风在内的全身性血栓栓塞风险的唯一批准的治疗选择，但直接口服抗凝剂 (DOAC) 的 超说明书使用正成为一种有吸引力的替代方法。我们旨在使用质量改进方法在三级心脏病中心改善 LV 血栓的诊断和管理。结果包括在 1 年内将 DOAC 的使用从 25%增加到 70%，并按照指南建议将从诊断到重复成像的时间缩短至 3-6 个月内。在第一个计划-执行-研究-行动 (PDSA) 周期中，我们确定了 2012 年 12 月 1 日至 2018 年 6 月 30 日期间诊断为 LV 血栓的 84 名患者。大多数（74%）患者服用 VKA。89%的患者进行了重复成像，但只有 55%的患者使用相同的方式。从诊断到重复成像的平均时间为 233±251 天。在血栓溶解、全身性栓塞或临床显著出血方面，VKA 和 DOAC 之间没有显著差异。我们发布了一份针对 LV 血栓管理的信托范围内的指南，其中包括支持使用 DOAC 和适当的随访成像的建议。在 2019 年 10 月 1 日至 2020 年 3 月 31 日进行的第二次 PDSA 周期中，又确定了 20 名患者。DOAC 的使用率增加到 70%，70%的患者在平均 140±61 天后进行了随访成像，尽管只有 36%的患者使用了相同的方式。使用质量改进方法，我们确认了在 LV 血栓的情况下安全有效地使用 DOAC。我们发布了信托范围内的指南支持其使用，这与我们的建议一致，DOAC 的使用增加，随访成像更早。
