Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus

医学 左心室血栓 内科学 心脏病学 四分位间距 狼牙棒 危险系数 心肌梗塞 冲程(发动机) 射血分数 人口 置信区间 经皮冠状动脉介入治疗 心力衰竭 环境卫生 机械工程 工程类
作者
Benoît Lattuca,N Bouziri,Mathieu Kerneïs,Jean-Jacques Portal,Jian-Nong Zhou,Marie Hauguel‐Moreau,Amel Mameri,Michel Zeitouni,Paul Guedeney,Nadjib Hammoudi,Richard Isnard,Françoise Pousset,Jean‐Philippe Collet,Éric Vicaut,Gilles Montalescot,Johanne Silvain
出处
期刊:Journal of the American College of Cardiology [Elsevier BV]
卷期号:75 (14): 1676-1685 被引量:159
标识
DOI:10.1016/j.jacc.2020.01.057
摘要

Contemporary data are lacking regarding the prognosis and management of left ventricular thrombus (LVT). The purpose of this study was to quantify the effect of anticoagulation therapy on LVT evolution using sequential imaging and to determine the impact of LVT regression on the incidence of thromboembolism, bleeding, and mortality. From January 2011 to January 2018, a comprehensive computerized search of LVT was conducted using 90,065 consecutive echocardiogram reports. Only patients with a confirmed LVT were included after imaging review by 2 independent experts. Major adverse cardiovascular events (MACE), which included death, stroke, myocardial infarction, or acute peripheral artery emboli, were determined as well as major bleeding events (BARC ≥3) and all-cause mortality rates. There were 159 patients with a confirmed LVT. Patients were treated with vitamin K antagonists (48.4%), parenteral heparins (27.7%), and direct oral anticoagulants (22.6%). Antiplatelet therapy was used in 67.9% of the population. A reduction of the LVT area from baseline was observed in 121 patients (76.1%), and total LVT regression occurred in 99 patients (62.3%) within a median time of 103 days (interquartile range: 32 to 392 days). The independent correlates of LVT regression were a nonischemic cardiomyopathy (hazard ratio [HR]: 2.74; 95% confidence interval [CI]: 1.43 to 5.26; p = 0.002) and a smaller baseline thrombus area (HR: 0.66; 95% CI: 0.45 to 0.96; p = 0.031). The frequency of MACE was 37.1%; mortality 18.9%; stroke 13.3%; and major bleeding 13.2% during a median follow-up of 632 days (interquartile range: 187 to 1,126 days). MACE occurred in 35.4% and 40.0% of patients with total LVT regression and those with persistent LVT (p = 0.203). A reduced risk of mortality was observed among patients with total LVT regression (HR: 0.48; 95% CI: 0.23 to 0.98; p = 0.039), whereas an increased major bleeding risk was observed among patients with persistent LVT (9.1% vs. 12%; HR 0.34; 95% CI: 0.14 to 0.82; p = 0.011). A left ventricular ejection fraction ≥35% (HR: 0.46; 95% CI: 0.23 to 0.93; p = 0.029) and anticoagulation therapy >3 months (HR: 0.42; 95% CI: 0.20 to 0.88; p = 0.021) were independently associated with less MACE. The presence of LVT was associated with a very high risk of MACE and mortality. Total LVT regression, obtained with different anticoagulant regimens, was associated with reduced mortality.
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