新型口服抗凝药物与华法林治疗左心室血栓的对照研究

评价新型口服抗凝药物(NOAC)与华法林治疗左心室血栓(LVT)的有效性和安全性。

入选2018年—2021年心脏超声诊断LVT并接受6个月以上抗凝治疗,同时完成1次及以上心脏超声随访的患者311例,分为NOAC组(76例)及华法林组(235例)。抗凝治疗6个月后随访LVT直径及主要不良心血管事件(MACE)。

NOAC组的抗凝有效率明显高于华法林组(97.4% vs 90.2%,P=0.046)。经(3.2±1.1)年的随访,两组MACE无差异。

NOAC对LVT的抗凝有效率高于华法林,安全性与之相当。

     

Is anticoagulating haemodialysis patients with non‐valvular atrial fibrillation too risky?

There is an increasing understanding of the risks from atrial fibrillation (AF) in the current era. In patients with end‐stage renal disease (ESRD) on dialysis, the prevalence of AF is significantly higher compared to the general population and those with earlier stages of CKD. Although anticoagulation of these patients may seem appropriate, there is a lack of conclusive evidence that it provides the same protection from thromboembolic complications as it does in patients not on dialysis. In addition, the increased risk of bleeding in patients requiring dialysis makes the use of anticoagulants less favourable. This article aims to discuss the problem of AF in dialysis patients, summarise the current evidence around the use of oral anticoagulants for AF in ESRD and provide some practical suggestions on management of AF in the haemodialysis population.     

Hypereosinophilic Syndrome Presenting with Biventricular Cardiac Thrombi

Hypereosinophilic syndrome is a rare condition characterized by idiopathic eosinophilia with organ system involvement. Cardiac involvement portends a less favorable prognosis as it can be complicated by development of heart failure, valvular dysfunction, and restrictive cardiomyopathy. We present a rare case of hypereosinophilic syndrome with FIP1L1/PDGFRA fusion in a 50‐year‐old male associated with thrombus in left and right ventricle. (Echocardiography 2010;27:E57‐E59)     

Physician compliance with outpatient oral anticoagulant guidelines in Auvergne, France

OBJECTIVE: Oral anticoagulants (OA) are commonly used, but they can lead to severe bleeding. We studied the indications and monitoring of OA in patients treated by general practitioners. DESIGN: Retrospective cross-sectional study. SETTING: Primary care. PATIENTS: Four hundred thirty-eight randomly selected patients of a population of 2,452 patients treated with OA were studied. INTERVENTIONS: We compared the indications for OA as reported by general practitioners with indications as defined according to recent guidelines. MAIN RESULTS: Twenty-five percent of patients should not have been treated with OA. Inappropriate indications (13% of patients) were atrial fibrillation without risk factor (3.9%), prior uncomplicated myocardial infarction (2.7%), peripheral arterial disease (2.7%), superficial thrombophlebitis (2.3%), and atherothrombotic ischemic stroke (1.6%). For 12% of patients, the duration of OA was too long (venous thromboembolism without permanent risk factor in 10%). Frequency of International Normalized Ratio (INR) measurement was insufficient for 14% of patients and target INR was not achieved in 31%. CONCLUSIONS: Our study demonstrated that clinicians' adherence to recommendations regarding indications for OA and management of this treatment should be improved. Implementation of anticoagulation clinics is probably needed.     

The vanishing vast ventricular thrombus.

A 54-year old man presented with multiple pulmonary emboli and an incidental finding of a huge left ventricular thrombus. Transthoracic echo images demonstrated a globally dilated heart with very poor left ventricular function. It was elected to manage the patient medically, and he was commenced on warfarin therapy, resulting in completed resolution of the thrombus over 10 weeks. No underlying cause was found and he did not experience any further embolic events. This illustrates a rare case of a large ventricular thrombus in a patient with no underlying risk factors.     

Risks factors for highly unstable response to oral anticoagulation: a case-control study

The factors associated with persistent instability of oral anticoagulant treatment (OAT) were investigated in a case-control study. The most unstable patients from 35 Italian anticoagulation clinics were matched with stable controls, for gender, age and OAT indication. Socio-demographic data, medical history, dietary and life habits, cytochrome P450 CYP2C9 variants, blood cell count, liver and renal functions were investigated. An 'Abbreviated Mental Test' (AMT) and a questionnaire to assess patient compliance to, and comprehension of, OAT indications and mechanisms were administered. An International Normalized Ratio (INR) above 4.5 was more frequently found in cases (n = 77) than controls (n = 80) (12.3% vs. 0.4%; P < 0.0001). The odds ratio for instability was significantly higher for: people who worked versus pensioners, acenocoumarol versus warfarin, and an insufficient score in the AMT and/or in the questionnaire. Cytochrome P450 CYP2C9 variants *1/*3 or *2/*3 or *3/*3 were more frequent among cases than controls (29.9% vs.15.0%; P = 0.042). No differences were observed as regards the other variables. In conclusion, we found that high intra-individual variability in OAT control was multifactorial, but poor OAT comprehension was prevalent.     

The Hemostatic Effects of Warfarin Titration in Post CABG Patients in Comparison to Placebo Treatment

Background: Since coronary artery bypass graft patients remain at risk of coronary artery and bypass graft occlusion after successful surgery, adjunct treatment regimens are under investigation. In a study of the patients of the multicenter Post Coronary Artery Bypass Graft (Post CABG) Trial, 1[emsp4 ]mg warfarin was found to have no important effect on coagulation parameters. Study design: The effects of 1, 2 and 3[emsp4 ]mg warfarin were evaluated at six-week intervals in 20 Post CABG Trial patients receiving titrated dose increases in comparison to 20 patients of similar age, gender and time from CABG treated with placebo. Results: International normalized ratio (INR) values increased with warfarin dose increments for 1, 2, and 3[emsp4 ]mg, respectively (0.95±0.16, 1.08±0.19, and 1.34±0.39) and in comparison to placebo treated patients (dose×treatment p<0.001). Factor VII coagulant activity decreased with warfarin titration (1[emsp4 ]mg, 119.0±18.3%%; 2[emsp4 ]mg, 100.6±32.8%%; 3[emsp4 ]mg, 95.0±27.8%%) and in comparison to placebo (dose×treatment p=0.008). Levels of prothrombin fragment F1.2, tissue plasminogen activator, fibrinogen and von Willebrand factor were unchanged with warfarin dose increments and in comparison to placebo. Conclusions: At doses up to 3[emsp4 ]mg, warfarin acts on the INR through a reduction of factor VII with no effect on the fibrinolytic system, fibrinogen or von Willebrand factor. At these doses F1.2 did not document reduced coagulation activity. The observations of this study were consistent with the decision in the Post CABG Trial to increase the warfarin dose above 1[emsp4 ]mg to achieve a distinct effect of warfarin that was less than full anticoagulation.     

不同抗凝强度华法林抗凝治疗对老年阵发性心房颤动患者预后的影响

目的探讨应用拜阿司匹林及不同抗凝强度的华法林抗栓对老年阵发性心房颤动(paroxysmal atrial fibrillation,PAF)患者预后的影响。方法选择老年PAF患者663例,并随机单盲分为4组:A组154例(拜阿司匹林150 mg/d),B组132例[华法林抗凝,国际标准化比值(INR)控制在1.2～1.6],C组197例(华法林抗凝,INR控制在1.7～2.5),D组180例(华法林抗凝,INR控制在2.6～3.0),随访近5年,记录4组终点事件及出血事件。结果与A组、B组比较,C组患者主要终点事件、次要终点事件、总主要事件、总事件所占的比例均明显下降(P<0.05,P<0.01);D组患者主要出血事件增加,总主要事件有所下降,但差异均无统计学意义(P>0.05)。结论老年PAF患者的抗凝治疗,华法林抗凝强度INR在1.7～2.5安全有效,而再增加抗凝强度并不增加获益,反而增加出血及其他事件发生率。     

Warfarin Is Not Needed in Low-Risk Patients Following Atrial Fibrillation Ablation Procedures

Background: The recently published HRS/EHRA/ECAS AF Ablation Consensus Statement recommended that warfarin should be used for at least 2 months following an AF ablation in all patients regardless of stroke risk factors. The objective of the study was to assess outcomes based upon anticoagulation practice after atrial fibrillation (AF) ablation to determine relative risk of a strategy of aspirin only in low-risk patients.
Methods: A total of 630 consecutive patients who underwent 934 ablation procedures using an open irrigated tip catheter for symptomatic AF were evaluated. Outcomes were compared between patients treated with warfarin (goal INR: 2–3) versus aspirin only (325 mg/day) in CHADS2 0–1 patients after ablation.
Results: Of the 690 patients, 123 (20%) were treated with aspirin and 507 (80%) with warfarin. Prevalences of the CHADS2 scores of patients on aspirin were (0: 40.7%, 1: 59.3%) and on warfarin (0: 13.6%, 1: 31.6%, ≥2: 54.8%), P < 0.0001. Patients in the warfarin group were older, had on average a lower ejection fraction, and had higher rates persistent/permanent AF, repeat ablations, hypertension, prior stroke/TIA, and diabetes. The 1-year survival free of AF for the total study population was 71.6%. There were no strokes/TIA in the aspirin group and 4 events (4 strokes, 0 TIAs) in the warfarin group. Two patients in the warfarin group died of fatal hemorrhage (1 intracranial, 1 gastrointestinal).
Conclusion: Select low-risk patients with a low CHADS2 (0–1) score who undergo left atrial ablation with an aggressive anticoagulation strategy with heparin and use of an open irrigated tip catheter with low CHADS2 scores can safely be discharged following their procedure on aspirin alone.     

心房颤动合并肿瘤患者应用新型口服抗凝剂的有效性及安全性的Meta分析

目的:评估新型口服抗凝剂(NOAC)相比华法林应用于心房颤动合并肿瘤患者中的有效性及安全性.方法:计算机检索Pubmed、EMBASE、Cochrane等数据库,并追踪以获文献的参考文献,检索时间范围为各数据库建库至2020年1月.按照纳入及排除标准筛选文献,并进行质量评价.应用Revman5.3软件对数据进行Meta...     

Thrombus in a Normal Left Ventricle: A Cardiac Manifestation of Pheochromocytoma

In this case report, a patient with a thrombus in a normal‐sized and functional left ventricular is described. The thrombus was most likely formed during pheochromocytoma crisis with severe transient wall motion abnormalities. (ECHOCARDIOGRAPHY 2010;27:195‐197)