左心室血栓治疗的系统回顾及meta分析

Therapy on left ventricular thrombus:Systematic review and meta-analysis

目的左心室血栓(left ventricular thrombus,LVT)是多种心脏疾病的并发症,血栓脱落可导致后果严重的体循环栓塞,因此及早治疗LVT极为重要。方法本文分别从抗凝治疗、溶栓治疗、抗血小板治疗、手术治疗4方面对LVT的治疗进行文献检索。在web of science,Ovid,EMBASE,Pubmed和Cochrane数据库应用“左心室血栓”“新型口服抗凝药”“Xa因子抑制剂”,“NOAC”,“DOAC”,“达比加群”,“利伐沙班”,“依度沙班”,“阿哌沙班”“维生素K拮抗剂”和“华法林”作为主题词进行检索。共25篇文章可用于meta分析以比较新型口服抗凝剂(direct oral anticoagulant,DOAC)与维生素K拮抗剂(vitamin K antagonist,VKA)的治疗效果及不良事件的发生率,对目前可检索到的应用肝素、抗血小板药物、溶栓、手术治疗LVT的文章进行系统回顾。结果DOAC治疗LVT的出血及卒中事件的发生率、全因死亡率低于VKA,而LVT的消失率、严重出血事件的发生率、出现全身栓塞事件的发生率两种治疗方法差异无统计学意义。溶栓治疗可有效治疗LVT。抗血小板治疗对LVT是否有效存在争议。手术作为LVT最有效直接的方法,全身栓塞事件的发生率最低。结论抗凝治疗是LVT最有效的治疗方法,在某些特定患者溶栓及手术时亦可选择应用,抗血小板治疗LVT是否有效仍存在争议。

Objective Left ventricular thrombus(LVT)is a complication of many cardiac diseases,thrombus detachment can lead to severe systemic embolism.Hence,early treatment of LVT is extremely vital.Methods The document retrieval was made from four aspects involving the anticoagulation therapy,thrombolytic therapy,antiplatelet therapy,and surgical therapy.The key words including“left ventricular thrombus”,“novel oral anticoagulants”,“factor Xa inhibitors”,“NOAC”,“DOAC”,“dabigatran”,“rivaroxaban”,“edoxaban”,“apixaban”,“vitamin K antagonist”,and“warfarin”were performed to search in the web of science,Ovid,EMBASE,Pubmed and Cochrane databases.A total of 25 articles were available for meta analysis to compare the efficacy and adverse events of novel oral anticoagulants(DOACs)versus vitamin K antagonists(VKA).Currently searchable articles on the use of heparin,antiplatelet drugs,thrombolytic therapy and surgery for LVT were systematically reviewed.Results The incidences of bleeding,stroke events and all-cause mortality of DOAC patients was lower than those of VKA patients.Differences in the incidence rate of left ventricular thrombus disappearance,severe bleeding events,systemic embolic events weren’t statistically significant between DOAC patients and VKA patients.Thrombolytic therapy is effective on LVT.The anti-platelet therapy remained controversial.Surgery was considered to be the most effective and direct method for LVT,and the incidence of systemic embolic events was minimum.Conclusion Anticoagulation is considered to be the most effective treatment for LVT,and thrombolysis or surgery is optionally used in some specific patients,the effectiveness of antiplatelet therapy remains controversial.