与华法林相比，直接口服抗凝剂治疗左心室血栓的应用

与华法林相比，直接口服抗凝剂治疗左心室血栓的应用。

Robinson AA等JAMA Cardiol 2020年4月22日

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摘要

缺血性和非缺血性心肌病患者可出现重要的左室血栓。抗凝被认为可以降低中风或系统性栓塞（SSE）的风险，但目前还没有关于直接口服抗凝剂（DOACs）治疗该病有效性的高质量数据。

目的比较DOAC与华法林治疗左室血栓的疗效。

设计、设置和参与者2013年10月1日至2019年3月31日期间，在3个三级护理学术医疗中心对514名超声心动图诊断为左室血栓的合格患者进行了队列研究。随访至研究期结束。

抗凝剂使用的暴露类型和持续时间。

主要结果和临床上明显的SSE测量。

结果514例（男性379例，平均年龄58.4（14.8）岁）合并左室血栓，其中华法林组300例，DOAC组185例（64例在两组间转换治疗）。患者队列的中位随访时间为351天（四分位间距，51-866天）。在未经调整的分析中，DOAC治疗与华法林使用（危险比[HR]，2.71；95%可信区间，1.31-5.57；P = .01）和既往SSE（HR，2.13；95%可信区间，1.22-3.72；P = .01）与SSE相关。在多变量分析中，DOAC与华法林抗凝（HR，2.64；95%CI，1.28-5.43；P = .01）和既往SSE抗凝（HR，2.07；95%CI，1.17-3.66；P = .01）仍与SSE显著相关。

结论在这项多中心队列研究中，DOAC治疗左室血栓的抗凝策略与使用华法林相比，即使在调整了其他因素后，发生SSE的风险也更高。这些结果挑战了左室血栓DOAC与华法林等效性的假设，并强调需要进行前瞻性随机临床试验，以确定最有效的左室血栓治疗策略。

Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi.

Robinson AA,et al  JAMA Cardiol             2020  Apr 22MOREAbstract           翻译         Importance Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication.Objective To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi.Design, Setting, and Participants A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period.Exposures Type and duration of anticoagulant use.Main Outcomes and Measures Clinically apparent SSE.Results A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE.Conclusions and Relevance In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.