D-二聚体及左心房前后径联合CHA_(2)DS_(2)-VASc评分排除非瓣膜性心房颤动患者左心房血栓的价值

Value of D-dimer and left atrial size combined with CHA_(2)DS_(2)-VASc score in excluding left atrial thrombosis in patients with non-valvular atrial fibrillation

目的探讨非瓣膜性心房颤动(NVAF)患者左心房血栓的危险因素,及是否可联合D-二聚体、左心房前后径及CHA_(2)DS_(2)-VASc评分排除左心房血栓。方法纳入2015年1月1日至2019年12月31日于北京大学人民医院行经食管超声心动图证实存在左心房血栓的75例NVAF患者为血栓组;2019年1月1日至10月31日检查无左心房血栓的80例NVAF患者为对照组。比较两组患者的临床资料、CHA_(2)DS_(2)-VASc评分、血液学指标和超声指标,采用多因素logistic回归模型分析与左心房血栓相关的因素。用相关因素的评分计算诊断左心房血栓的阳性预测值及阴性预测值。结果两组人群的年龄、性别、持续性房颤的比例及房颤时间差异均无统计学意义(均P>0.05),血栓组的CHA_(2)DS_(2)-VASc评分[M(Q1,Q3)]高于对照组[2.5(1.0,3.0)比1.8(1.0,3.0),P=0.012];凝血指标中血栓组凝血酶原活动度[M(Q1,Q3)]更低[81.1%(72.0%,93.0%)比88.8%(83.0%,96.0%),P=0.008]、活化部分凝血活酶时间[M(Q1,Q3)]更长[(32.1±4.8)比(30.2±3.7)s,P=0.006]、D-二聚体水平[M(Q1,Q3)]更高[231.0(71.5,272.2)比121.7(49.0,140.0)ng/ml,P<0.001];超声指标中血栓组左心房前后径更大[(44.6±6.6)比(38.9±5.3)mm,P<0.001]、左室射血分数[M(Q1,Q3)]更低[56.7%(45.8%,66.3%)比63.3%(60.5%,70.2%),P=0.003]、存在二尖瓣反流的比例更高(58.1%比26.8%,P<0.001)。与左心房内血栓形成独立相关的因素仅有左心房前后径,OR(95%CI)值为4.480(1.616~12.423)。联合D-二聚体、左心房前后径和CHA_(2)DS_(2)-VASc评分3个指标的新评分系统诊断左心房血栓的阴性预测值为100%。结论在NVAF患者中,与左心房血栓形成的相关因素为左心房前后径;结合D-二聚体、左心房前后径、CHA_(2)DS_(2)-VASc评分可在NVAF患者消融术前进一步排除左心房血栓。

Objective To investigate the related factors of thrombosis in patients with non-valvular atrial fibrillation(NVAF),and whether the combination of D-dimer,left atrial anteroposterior diameter and CHA_(2)DS_(2)-VASc score can be used to exclude left atrial thrombosis.Methods A total of 75 NVAF patients with left atrial thrombosis confirmed by transesophageal echocardiography in Peking University People′s Hospital from January 1,2015 to December 31,2019 were enrolled as the thrombus group.From January 1 to October 31,2019,80 patients with NVAF without left atrial thrombosis were enrolled as the control group.The clinical data,CHA_(2)DS_(2)-VASc score,hematological biomarkers,ultrasound data of two groups were compared.The independent factors associated with left atrial thrombosis were screened by univariate analysis and multivariate logistic regression analysis.The positive predictive value and negative predictive value for the diagnosis of left atrial thrombosis were gained by the score calculated based on the independent related factors.Results There were no significant differences in age,gender,proportion of persistent atrial fibrillation and duration of atrial fibrillation between the two groups.The CHA_(2)DS_(2)-VASc score[M(Q1,Q3)]of the thrombus group was higher than that of the control group[2.5(1.0,3.0)vs 1.8(1.0,3.0),P=0.012].The prothrombin time activity[M(Q1,Q3)]of the thrombus group was 81.1(72.0,93.0)%,which was lower than that of the control group 88.8(83.0,96.0)%(P=0.008).The activated partial thromboplastin time(APTT)of the thrombus group was longer than that of the control group[(32.1±4.8)s vs(30.2±3.7)s,P=0.006].D-dimer[M(Q1,Q3)]of the thrombus group was 231.0(71.5,272.2)ng/ml,which was higher than that of the control group 121.7(49.0,140.0)ng/ml(P<0.001).The left atrial anteroposterior diameter in thrombus group was larger[(44.6±6.6)mm vs(38.9±5.3)mm,P<0.001],the proportion of mitral regurgitation was higher(58.1%vs 26.8%,P<0.001).The left ventricular ejection fraction[M(Q1,Q3)]of the thrombus group was 56.7%(45.8%,66.3%),which was lower than that of the control group 63.3%(60.5%,70.2%)(P=0.003).Multivariate logistic regression analysis showed that the factor related to left atrial thrombosis was left atrial anteroposterior diameter(OR=4.480,95%CI:1.616-12.423).The negative predictive value of the new scoring system combined with D-dimer,left atrial anteroposterior diameter and CHA_(2)DS_(2)-VASc score for left atrial thrombosis was 100%.Conclusions In NVAF patients,the factor independently associating with left atrial thrombosis is left atrial anteroposterior diameter.The combination of D-dimer,left atrial anteroposterior diameter,and CHA_(2)DS_(2)-VASc score can help exclude left atrial thrombosis before ablation of NVAF.