非瓣膜病性心房颤动合并心房血栓患者的临床特征及溶栓效果分析

Analysis of diagnosis and anticoagulation therapy in the non-valvular atrial fibrillation with atrial thrombi

目的通过观察非瓣膜病性心房颤动(简称房颤)合并心房血栓患者的临床特征及其溶栓治疗效果,探讨心脏基础疾病对心房血栓位置和溶栓效果的影响。方法回顾性分析本院初次诊断为心房血栓的非瓣膜病性房颤患者的病历资料。通过住院病历资料提取临床特征、心房血栓部位、确诊前抗凝治疗情况、确诊后抗栓治疗方案,计算CHADS_2和CHA_2DS_2-VASc积分。根据患者临床随访的影像学检查结果判断血栓是否溶解并计算血栓溶解时间。根据患者是否合并心肌病分为心肌病组和非心肌病组。结果共入选78例,心房血栓部位分布表现:53例(67.9%)仅见于左心耳,5例(6.4%)仅见于左房,17例(21.8%)左房和左心耳同时存在,3例(3.9%)仅见于右房。心肌病组(n=38)单纯左心耳血栓发生比例低于非心肌病组(52.6%vs 62.3%,P=0.0047),右房血栓均为心肌病组患者。CHA_2DS_2-VASc积分识别高危(≥2分)患者能力高于CHADS2积分(80.8%vs 38.5%,P<0.0001)。确诊前30.9%未抗栓治疗,21.8%仅仅口服阿司匹林;42.3%口服华法林,其中仅有7.7%患者国际正常化比值≥2.0;5.1%口服新型抗凝药物。72例(92.3%)患者抗栓治疗后平均(6.5±4.2)个月的随访中重复同样检查,其中51例(71.8%)证实血栓溶解。心肌病组血栓溶解成功率低于非心肌病组[60%(21/35)vs 81.1%(30/37),P=0.028 9]。Logstic回归分析证实心肌病能独立预测溶栓治疗效果(OR=-1.20±0.56,P=0.043 6)。结论左心耳仍是非瓣膜病性房颤患者心腔内血栓形成最常见的部位,但心肌病患者更易发生心房内血栓。抗凝治疗认识不足和治疗不规范与血栓形成密切相关。CHA_2DS_2-VASc积分进行血栓风险评估优于CHADS_2积分。心肌病是预测溶栓治疗效果的独立危险因素。

Objective We retrospectively analyzed the clinical features and therapeutic outcomes in the patients of non-valvular atrial fibrillation（NVAF） complicated with atrial thrombosis. Methods Seventy-eight patients of NVAF with atrial thrombus diagnosed for the first time were enrolled in a single center. The clinical features of all patients were analyzed, including the CHADS2/CHA2DS2-VASc scores, location of thrombosis, anti-thrombosis therapy before and after diagnosis. We defined thrombi dissolving as the disappearance of thrombi with same screen- ing methods during follow-up. The patients were divided into two groups by whether combined with cardiomyopa- thy, non-cardiomyopathy（non-CM） group and cardiomyopathy（CM） group Results There were 53 patients （67. 9%） of thromhi found only in the left atrial appendages（LAA）, 5 patients （6.4%） only in the left atrium（LA）, 17 patients （21.8%） both in the LA and LAA, and 3 patients （3.9%） only in the right atrium（RA）. The proportion of only-LAA thrombi was higher in the non-CM group than that in the CM group （62.3% and 52.6%, P=0. 004 7）. The 3 patents with RA thrombi were all in the CM group. The screening ability of CHA2DS2 VASc score system was powerful distinguish than CHADS2 score system （80.8% and 38.5 %, P〈0.000 1）. Before this research, 30.9% patients didnrt take any anti-thrombo- sis drugs, 21.8% only took aspirin. There were 42.3% patients with warfarin before diagnosis, and only 7.7 % had INR≥2.0. Seventy-two patients （92.3 %） had repeated the same imaging method after mean （6.5 ± 4.2） months with anticoagulation, 71.8% of which （51 cases） were proved thrombi dissolved, and 7.7% of which had lost follow up （3 cases in each group）. The rate of thrombi dissolving was higher in the non-CM group than in the CM group （81.1% and 60%, P =0.028 9）. CM was an independent risk factor to predict atrial thrombi dissolving after Logis- tic regression analysis （OR=-1.20±0.56, P =0.043 6）. Conclusion LAA is still common site for cardiogenic thrombosis in the NVAF patients, however, the patients with cardiomyopathy are more likely to have thrombi in the left or right atrium. The deficiency of anticoagulation is related to the thrombosis. CHA2 DS2-VASc is superior to CHADS2 in predicting the thrombosis risk. Cardiomyopathy is an independent risk factor for the atrial thrombi dis- solving in NVAF patients.