В обзоре представлены данные о частоте выявления тромбоза в левом предсердии (ЛП и/или его ушке (уЛП) у больных с неклапанной фибрилляцией предсердий (нФП), охарактеризована их связь с проводимой антитромботической терапией и наличием сердечно-сосудистых факторов риска. Продемонстрировано, что тромбоз в ЛП/уЛП выявляется в 4-19% случаев. При этом данные о частоте тромба в ЛП/уЛП получены при обследовании небольших когорт пациентов с ФП, подвергнутых чреспищеводной эхокардиография перед катетерной изоляцией устьев легочных вен, кардиоверсией, установкой окклюдеров в уЛП. Информация о частоте тромбоза в ЛП/уЛП вне проведения указанных процедур крайне ограничена. Частота выявления тромба в ЛП/уЛП варьируется в зависимости контингента изученных, наличия сердечно-сосудистых факторов риска (сахарный диабет, метаболический синдром, артериальная гипертензия, хроническая болезнь почек, хроническая сердечная недостаточность) и особенностей антикоагулянтной терапии. Шкалы CHADS 2 и CHA2DS 2-VASc недостаточно хорошо предсказывают наличие тромба в ЛП/уЛП. Так, по меньшей мере 50% больных с тромбом ЛП/уЛП могут иметь низкий балл согласно этим шкалам и, соответственно, риск сердечных тромбоэмболий у них будет недооценен. Согласно накопленным фактам адекватная антикоагулянтная терапия не гарантирует отсутствия тромба в ЛП/уЛП. Причем примерно в 40% случаев тромботические образования в ЛП/уЛП не исчезают через 1 год антитромботического лечения.
The article presents results of analysis of the register of out-patients and in-patients with atrium fibrillation (n=1624) observed in 2009-2015. The retrospective data analysis and prospective observation of certain percentage of patients were applied to evaluate rate and conformity of implementation of various groups of anti-thrombotic medications in conditions of real practice of polyclinics and hospitals of Moscow. The results are compared with data of national studies of this issue during recent years.
Funding Acknowledgements Type of funding sources: None. Background. Left atrial thrombus (LAT) is the main source of cardiac emboly in patients with non-valvular atrial fibrillation (NAF). Several risk scores – mostly modified CHADS2 and CHA2DS2-VASc – were offered to predict LAT in patients with NAF. However, their relative predictive value requires further evaluation. Purpose. Compare the ability of different risk scores to predict LAT before catheter ablation or cardioversion in patients with NAF. Methods. In a retrospective single-center study, medical records of 1994 patients with NAF who underwent transesophageal echocardiography before catheter ablation or cardioversion were analyzed. LAT was identified in 33 (1.6%) of them. For the control group 167 patients without LAT were randomly selected from this database. Logistic regression analysis and C-statistic were used for evaluation and comparison of predictive values of CHADS2, R2CHADS2, CHA2DS2-VASc, R-CHA2DS2-VASc, R2CHA2DS2-VASc, CHA2DS2-VASc-RAF, mCHA2DS2-VASc and CHA2DS2-VASc-AFR scores. Results. The mean age of studied patients was 60.3 ± 10.9 years, 110 (55%) of them were males. The mean CHA2DS2-VASc score was 2.54 ± 1.79. Results of univariate analysis and C-statistic for above mentioned risk scores are presented in the table. Each of them was associated with LAT. In comparison with a CHA2DS2-VASc score C-statistic was significantly higher for CHA2DS2-VASc-RAF and CHA2DS2-VASc-AFR scores (p values 0.03 and 0.001 respectively). In multivariate analysis only CHA2DS2-VASc-RAF score was associated with LAT (OR 1.37; 95% CI 1.21-1.55, p < 0.0001). OR for LАT in patients with CHA2DS2-VASc-RAF >3 was 12.8 (95% CI 3.75-43.9; p < 0.0001) with sensitivity, specificity, positive and negative predictive values 90.6%, 57.1%, 33.3% and 58.9% respectively. Conclusion. In a group of patients with NAF and relatively low incidence of LAT all studied scores were associated with LAT and CHA2DS2-VASc-RAF score has appeared the most informative. Predictors of LAT in patients with NAF Risk stratification models OR (95% CI) p-value C-statistic (95% CI) CHADS2 2.12 (1.55-2.91) <0.0001 0.77 (0.68-0.85) R2CHADS2 2.00 (1.53-2.62) <0.0001 0.78 (0.69-0.87) CHA2DS2-VASc 1.65 (1.36-2.05) <0.0001 0.74 (0.65-0.84) R-CHA2DS2-VASc 1.64 (1.34-2.03) <0.0001 0.76 (0.66-0.85) R2CHA2DS2-VASc 1.59 (1.32-1.92) <0.0001 0.76 (0.66-0.85) CHA2DS2-VASc- RAF 1.35 (1.27-1.52) <0.0001 0.84 (0.76-0.91) mCHA2DS2-VASc 1.83 (1.42-2.35) <0.0001 0.75 (0.65-0.85) CHA2DS2-VASc-AFR 1.75 (1.41-2.17) <0.0001 0.80 (0.71-0.88)
Aim. To study the potential of predicting thrombosis of the left atrium (LA) and/or LA appendage (LAA) before catheter ablation (CA) or elective cardioversion in patients with nonvalvular atrial fibrillation (NAF) or atrial flutter (AFL) using indicators available in routine practice.Material and methods. In this single-center retrospective study, the medical records of 1994 patients with nAF or AFL for the period 2014-2019 were analyzed, who underwent transesophageal echocardiography before CA or elective CV. LA/LAA thrombus was found in 33 (1,6%) patients. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic, clinical, laboratory data, results of transthoracic echocardiography, as well as the CHA2DS2-VASc-RAF (CHA2DS2-VASc plus 2 points for an estimated glomerular filtration rate <56 ml/min/1,73 m2, 4 points for persistent AF (lasting >7 days), 10 points for persistent AF).Results. The mean age of the patients was 60,3±10,9 years (men, 55%). There were more patients with NAF (87,5%), hospitalized for CV (84,0%). Multivariate analysis revealed that the severity of symptoms associated with arrhythmia was associated with the detection of a LA/LAA thrombus (odds ratio (OR) for EHRA class 3-4 14,29 at 95% confidence interval (CI): 3,3-61,8; p<0,0001), left ventricular ejection fraction <48% (OR, 7,83; 95% CI: 1,2-53,05; p=0,035) and total CHA2DS2-VASc-RAF score (OR, 1,29 at 95% CI: 1,08-1,5; p=0,004). Supplementation of the CHA2DS2-VASc-RAF with new independent predictors of LA/LAA thrombosis did not lead to a significant increase in the area under the characteristic curve, which was 0,83 (95% CI: 0,76-0,91) and 0,87 (95% CI: 0,80-0,94), respectively (p=0,13). The OR of LA/LAA thrombosis with a total score CHA2DS2-VASc-RAF >3 was 12,8 (95% CI: 3,8-43,9; p<0,0001), while the sensitivity, specificity, positive and negative predictive value — 90,6, 57,1, 30,2 and 96,7% respectively. The OR of thrombosis of LA/LAA with a CHA2DS2-VASc-RAF score >8 was 25,8 (95% CI: 5,9-112,3; p<0,0001), while sensitivity, specificity, positive and negative predictive value — 93,5, 64,0, 34,9 and 97,9%, respectively.Conclusion. When predicting LA/LAA thrombosis, detected during transesophageal echocardiography before CA or elective CV in patients with NAF or AFL who did not have a pronounced structural heart pathology and severe concomitant diseases, taking into account the severity of symptoms associated with arrhythmia and a reduced left ventricular ejection fraction (<48%) in addition to the risk stratification scale for LA/LAA thrombosis CHA2DS2-VASc-RAF did not lead to an increase in the area under the characteristic curve, but made it possible to increase the OR of LA/LAA thrombosis detection by 2 times and increase the sensitivity, specificity, positive and negative predictive value.
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