Sacoransky Ethan, Ke Danny Yu Jia, Alexander Bryce, Abuzeid Wael
Queen's University School of Medicine, Kingston, Ontario, Canada.
Queen's University School of Medicine, Kingston, Ontario, Canada.
Am J Cardiol. 2024 Apr 15;217:10-17. doi: 10.1016/j.amjcard.2024.02.023. Epub 2024 Feb 25.
Clinical practice guidelines from the American Heart Association recommend consideration of prophylactic anticoagulation to prevent left ventricular thrombus (LVT) formation in patients with anterior ST-elevation myocardial infarction. These guidelines were given a low certainty of evidence (class IIb, level C), relying primarily on case studies and expert consensus to inform practice. Our objective was to compare the safety and efficacy of prophylactic anticoagulation, in addition to dual antiplatelet therapy, in the current era of timely primary percutaneous coronary intervention. Electronic databases, including EMBASE, MEDLINE, and Cochrane Library, were systematically searched from January 2012 through June 2022. A total of 7,378 publications were screened, and 5 publications were eventually included in this review: 1 randomized control trial and 4 retrospective studies involving 1,461 patients. Data were pooled using a fixed-effects model and reported as odds ratios (ORs) with 95% confidence intervals (CIs). The primary outcome of interest was the rate of LVT formation, and the secondary outcomes were the rate of major bleeding and systemic embolism. Pooled analysis showed a significantly lower rate of LVT formation (OR 0.28, 95% CI 0.11 to 0.73, p <0.01) and significantly higher rates of bleeding (OR 2.85, 95% CI 1.13 to 7.24, p = 0.03) in the triple therapy group compared with dual antiplatelet therapy. No significant difference was observed in the rate of systemic embolism between the groups (OR 0.37, 95% CI 0.12 to 1.13, p = 0.08). In this meta-analysis, there is no conclusive evidence to either support or oppose the use of triple therapy for LVT prevention in patients with anterior ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Appropriately powered randomized controlled trials are warranted to further evaluate the benefits of LVT prevention against the risks of major bleeding in this population.
美国心脏协会的临床实践指南建议，对于前壁ST段抬高型心肌梗死患者，应考虑预防性抗凝以防止左心室血栓（LVT）形成。这些指南的证据确定性较低（IIb类，C级），主要依靠病例研究和专家共识来指导实践。我们的目的是在当前及时进行直接经皮冠状动脉介入治疗的时代，比较预防性抗凝联合双联抗血小板治疗的安全性和有效性。从2012年1月至2022年6月，系统检索了包括EMBASE、MEDLINE和Cochrane图书馆在内的电子数据库。共筛选了7378篇出版物，最终5篇出版物纳入本综述：1项随机对照试验和4项回顾性研究，涉及1461例患者。采用固定效应模型汇总数据，并以比值比（OR）及95%置信区间（CI）报告。感兴趣的主要结局是LVT形成率，次要结局是大出血和系统性栓塞率。汇总分析显示，与双联抗血小板治疗相比，三联治疗组的LVT形成率显著降低（OR 0.28，95%CI 0.11至0.73，p<0.01），出血率显著升高（OR 2.85，95%CI 1.13至7.24，p = 0.03）。两组间系统性栓塞率无显著差异（OR 0.37, 95%CI 0.12至1.13，p = 0.08）。在这项荟萃分析中，没有确凿证据支持或反对在接受直接经皮冠状动脉介入治疗的前壁ST段抬高型心肌梗死患者中使用三联疗法预防LVT。需要开展有足够样本量的随机对照试验，以进一步评估该人群中预防LVT的益处与大出血风险。
