不同剂量非维生素K拮抗剂口服抗凝药治疗非瓣膜性心房颤动合并左心耳血栓的有效性和安全性观察

The safety and efficacy of standard versus low dose non-vitamin K antagonist oral anticoagulants in patients with nonvalvular atrial fibrillation and left atrial appendage thrombi

目的观察不同剂量非维生素K拮抗剂口服抗凝药(NOACs)治疗非瓣膜性心房颤动(房颤)合并左心耳血栓(LAAT)的有效性和安全性。方法入选2016年10月至2020年9于邵阳市中心医院心血管内科住院拟行介入治疗或电复律的非瓣膜性房颤患术前经食道超声心动图(TEE)提示LAAT并接受NOACs治疗的27例患者,根据药物剂量分为标准剂量组(达比加群150 mg,2/d;利伐沙班20 mg,1/d)和低剂量组(达比加群110 mg,2/d;利伐沙班15 mg,1/d),低剂量NOACs使用人群包括高龄(年龄≥75岁)、低体重(<50 kg)及肾功能不全(肌酐清除率<50 ml/min),至少治疗3周。治疗后1月、2月及3月复查TEE,比较LAAT消退情况,并观察治疗过程中血栓栓塞及出血事件发生率。结果共入选27例患者,其中标准剂量组15例(利伐沙班8例,达比加群7例),低剂量组12例(利伐沙班9例,达比加群3例)治疗3月后,标准剂量组13例(86.7%)LAAT完全消退,1例较前缩小,1例无变化;低剂量组9例LAAT完全消退(75%),2例较前缩小,1例无变化。两组患者治疗后LAAT完全消退比例接近(P>0.05),且治疗过程中均无血栓栓塞及主要出血事件发生。结论低剂量和标准剂量NOACs治疗非瓣膜性房颤合并LAAT安全性和有效性相当,提示在特殊人群中使用低剂量NOACs治疗LAAT是可行的,但上述结果仍需大规模前瞻性研究进行验证。

Objective To investigate the safety and efficacy of standard versus low dose non-vitamin K antagonist oral anticoagulants(NOACs)in patients with nonvalvular atrial fibrillation(NVAF)and left atrial appendage thrombi(LAAT).Methods 27 patients with NVAF who underwent transesophageal echocardiography(TEE)before interventional procedures or cardioversion for the detection of left atrial appendage thrombi(LAAT)and were treated with NOACs from October 2016 to September 2020 in the Central Hospital of Shaoyang was retrospectively screened.The study population was divided into two groups according to the dose of NOACs:standard dose group(dabigatran 150 mg,twice daily;rivaroxaban 20 mg,once daily)and low dose group(aged≥75 years,body weight<50 kg,or creatinine clearance<50 ml/min;dabigatran 110mg,twice daily;rivaroxaban 15mg,once daily).Repeated TEE was performed 1,2,and 3 months later.The rate of LAAT completely resolved and incidence of thromboembolic and major bleeding events were compared between the two groups.Results A total of 27 patients were included,15 patients in the standard dose group and 12 in the low dose group.After 3 months,LAAT was completely resolved in 13 out of 15(86.7%)and 9 out of 12(75%)patients treated with standard and low dose NOACs,respectively.The rate of LAAT completely resolved was comparable between groups(P>0.05).No thromboembolic or major bleeding events occurred during follow-up.Conclusion Low-dose NOAC was a safe and effective option for the treatment of LAAT in special populations.However,the results warrant validation in a prospective study.