左心室血栓治疗的系统回顾及meta分析

doi:10.3969/j.issn.1004-583X.2023.02.001

摘要/Abstract

摘要：

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。

关键词: 左心室血栓, 抗凝治疗, 抗血小板治疗, 溶栓治疗, 手术

Abstract:

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.

Key words: left ventricular thrombus, anticoagulation therapy, antiplatelet therapy, thrombolytic therapy, surgery

中图分类号:

R543

周慧贤, 周亚青, 郭甘霖, 崔炜. 左心室血栓治疗的系统回顾及meta分析[J]. 临床荟萃, 2023, 38(2): 101-110.

Zhou Huixian, Zhou Yaqing, Guo Ganlin, Cui Wei. Therapy on left ventricular thrombus:Systematic review and meta-analysis[J]. Clinical Focus, 2023, 38(2): 101-110.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.02.001

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I2/101

图/表 11

图1 文章筛选流程图

Fig.1 Flow diagram of articles selection

表1 纳入研究的基本情况

Tab. 1 Characteristics of included studies of the meta-analysis

作者	发表年份		研究类型		随访年限	LVT的原因		DOAC vs VKA		LVT的消失率 (DOAC vs VKA)
Herald^[2]	2022		回顾性队列研究		中位数:3.4年	未记录		134 vs 299		未记录		27.6% vs 37.8%[ $H R$ :0.59(0.40-0.87), $P$ =0.007]
Zhang^[3]	2022		单中心,回顾性研究		24个月	STEMI-PCI术后		33 vs 31		6个月:42.4% vs 19.4% [ $H R$ :3.0(1.0-8.97)]; 12个月:69.7% vs 48.4%[ $H R$ :2.13(1.02-4.46)]; 18个月:78.8% vs 64.5%[ $H R$ :1.96(1.01-3.79)];24个月:78.8% vs 74.2%[ $H R$ :1.70(0.90-3.22)]		6.1% vs 9.7%[ $H R$ :0.48(0.73-3.20)]
Tamimi^[4]	2022		单中心,回顾性研究		6个月	131例患者(66.4%)有缺血性心肌病,其他患者不详		48 vs 116		66.6% vs 79.3% ( $P$ =0.08)		10.0% vs 8.0% ( $P$ =0.768)
Aldaas^[5]	2022		单中心,回顾性研究		中位数:7.2个月(新型口服抗凝药),10个月(华法林)	未记录		76 vs 146		13.2% vs 16.4%[HR 0.08(95% $C I$ : 0.00-2.57); $P$ =0.154]		未记录
Varwan^[6]	2021		单中心,回顾性研究		2年	心肌梗死(28%),慢性缺血性心肌病(42%),非缺血性心肌病(30%)		58 vs 34		55.6% vs 64.0% ( $P$ =0.51)		5.2% vs 5.9% ( $P$ =1.0)
Jones^[7]	2020		单中心、观察性、前瞻性研究		中位数:2.2年	心肌梗死		41 vs 60		151天:70.7% vs 48.3% ( $P$ =0.04) 1年: 82.0% vs 64.4% ( $P$ =0.0018) 利伐沙班、阿哌沙班和依度沙班的LVT消失率:88%, 93%, 100%		14.6% vs 36.7% ( $P$ =0.318)
Albabtain^[8]	2021		单中心,回顾性研究		利伐沙班治疗的中位数:9.5个月(25%~75%的可信区间:6~32.5个月),华法林治疗的中位数:14个月(25%~75%的可信区间:3~41个月)	心肌梗死,扩张型心肌病,心力衰竭		28 vs 35		71.4% vs 68.6% LVT消失的中位时间: 3(2~11.5)个月vs 9 (4~20)个月( $P$ =0.019)		7.1% vs 2.9% ( $P$ =0.23)
Mihm^[9]	2021		单中心,回顾性队列研究		6个月	心肌梗死,心肌病,心力衰竭,瓣膜性心脏病		33 vs 75		58.3% vs 65%		15.2% vs 2.7% ( $P$ =0.027)
Xu^[10]	2021		单中心,回顾性队列研究		2.37±2.1年 vs 2.24±2.5年	未记录		25 vs 62		76.0% vs 74.2% ( $P$ =0.057)		4.0% vs 3.2% ( $P$ =0.858)
Bass^[11]	2021		多中心,回顾性队列研究		90 d	未记录		180 vs 769		未记录		7.8% vs 10.9% ( $P$ =0.20)
Abdelnabi^[12]	2021		多中心、开放性、前瞻性、随机临床试验		未记录	未记录		39 vs 40		1个月 :71.8% vs 47.5% ( $P$ =0.03); 3个月:76.9% vs 67.5%( $P$ =0.35); 6个月:87.2% vs 80.0%( $P$ =0.39)		5.1% vs 15% ( $P$ =0.11)
Alcalai^[13]	2021		多中心、开放性、前瞻性、随机临床试验		3个月	心肌梗死后		17 vs 15		94.1% vs 93.3%		0.0%vs 13.3%
Guddeti^[14]	2020		多中心、回顾性研究		随访中位数:1年,平均随访时间: 10.4±3.4 个月	缺血性心肌病和非缺血性心肌病		19 vs 80		80.0% vs 81.0% ( $P$ =0.9)		5.3% vs 5.0%( $P$ =0.96)
Robinson^[15]	2020		多中心、队列研究		随访中位数:351 天	缺血性心肌病和非缺血性心肌病		121 vs 236		NR		6.6% vs 8.1%
Ratnayake^[16]	2020		单中心、回顾性、观察性、队列研究		6个月	ST段抬高型心肌梗死		2 vs 42		50.0% vs 81.0%		未记录
Iqbal^[17]	2020		单中心、回顾性、观察性、队列研究		评价随访时间: 3.0±1.4年	缺血性心肌病、扩张型心肌病、肥厚性心肌病、病因不详		22 vs 62		65.0% vs 76.0% ( $P$ =0.33)		0.0% vs 10.0% ( $P$ =0.13)
Ali^[18]	2020		单中心、回顾性研究		1年	慢性缺血性心肌病(58%),非缺血性心肌病(23%)		32 vs 60		56.3% vs 62.0% ( $P$ =0.85)		0.0% vs 3.3%
Willeford^[19]	2021		单中心、回顾性研究		1年	心肌梗死,心力衰竭,冠心病		22 vs 129		59.1% vs 48.8% ( $P$ =0.37)		4.5% vs 3.9% ( $P$ =1)
Alcalai^[20]	2021		多中心、开放性、前瞻性、随机临床试验		3个月	心肌梗死		13 vs 12		92.3% vs 100%		0.0% vs 16.7%
Alizadeh^[21]	2019		前瞻性、观察性研究		中位数:1.8年	心肌梗死		38 vs 60		75.0% vs 53.0% ( $P$ =0.0018)		0.0% vs 5.0% ( $P$ =0.030)
Gama^[22]	2019		单中心、回顾性、队列研究		未记录	心肌梗死,射血分数减低的心力衰竭		12 vs 52		91.7% vs 59.6%		未记录
Cochran^[23]	2021		回顾性研究		12个月	未记录		14 vs 59		76.3% vs 85.7% ( $P$ =0.721)		14.3% vs 13.65 ( $P$ =1)
Daher^[24]	2020		观察性、回顾性研究		3个月	心肌梗死,缺血性心肌病		17 vs 42		70.6% vs 71.4%( $P$ =0.9)		未记录
Jaidka^[25]	2018		回顾性研究		6个月	心肌梗死		12 vs 37		88.9% vs 69.2% ( $P$ =0.245)		25.0% vs16.2%
Yunis^[26]	2020		回顾性队列研究		24个月	未记录		64 vs 200		97.0% vs 100.0%( $P$ =0.4)		6个月:3.2% vs 1.5%( $P$ =0.46) 12个月:5.1% vs 2.1%( $P$ =0.88) 24个月:5.1% vs 4.9%( $P$ =0.12)
作者		严重出血事件 (DOAC vs VKA)		轻微出血事件 (DOAC vs VKA)			脑卒中 (DOAC vs VKA)		全身栓塞事件 (DOAC vs VKA)		全因死亡率 (DOAC vs VKA)
Herald^[2]		未记录		未记录			19.4% vs 24.4%[ $H R$ :0.75(0.48-1.19), $P$ =0.22]		21.6% vs 28.1%[ $H R$ :0.65(0.42-1.02), $P$ =0.59]		23.9% vs 46.2%[ $H R$ :0.48(0.32-0.74), $P$ =0.0008]
Zhang^[3]		24个月:0.0% vs 3.2%		24个月:6.0% vs 6.4%			未记录		24个月:3.0% vs 12.9%[ $H R$ :0.29(0.02-3.13)]		24个月:3.0% vs 12.9%[ $H R$ :0.226(0.02-2.62)]
Tamimi^[4]		未记录		未记录			未记录		未记录		未记录
Aldaas^[5]		未记录		未记录			未记录		未记录		未记录
Varwan^[6]		未记录		未记录			1.7% vs 2.9%( $P$ =1.0)		1.7% vs 2.9%( $P$ =1.0)		未记录
Jones^[7]		未记录		未记录			2.4% vs 5%( $P$ =0.388)		2.4% vs 5%( $P$ =0.388)		0.0% vs 0.0%
Albabtain^[8]		未记录		未记录			3.8% vs 2.9%( $P$ =0.99)		3.8% vs 0.0%		7.14% vs 8.57%( $P$ =0.64)
Mihm^[9]		15.2% vs 2.7% ( $P$ =0.027)		未记录			6.1% vs 5.3%		9.1% vs 5.4%		12.1% vs 8%
Xu^[10]		未记录		未记录			4.0% vs 4.8% ( $P$ =0.158)		4.0% vs 6.5% ( $P$ =0.657)		8.0% vs 4.8% ( $P$ =0.566)
Bass^[11]		未记录		未记录			7.8% vs 11.7% ( $P$ =0.13)		33.0% vs 30.6% ( $P$ =0.53)		未记录
Abdelnabi^[12]		5.1% vs 15% ( $P$ =0.11)		未记录			0.0% vs 10.0% ( $P$ =0.08)		0.0%vs 15.0% ( $P$ =0.01)		未记录
Alcalai^[13]		0.0% vs 13.3%		未记录			未记录		0.0% vs 6.7%		5.9% vs 0.0%
Guddeti^[14]		未记录		未记录			0.0% vs 2.5%( $P$ =0.49)		0.0% vs 2.5%( $P$ =0.49)		未记录
Robinson^[15]		未记录		未记录			未记录		14.0% vs 5.9%( $P$ =0.01)		11.6% vs 13.6%
Ratnayake^[16]		未记录		未记录			未记录		未记录		未记录
Iqbal^[17]		未记录		未记录			0.0% vs 2.0%( $P$ =0.55)		0.0% vs 4.0%( $P$ =0.55)		14.0% vs 10.0%( $P$ =0.61)
Ali^[18]		未记录		未记录			2 vs 7		6.7% vs 20%		未记录
Willeford^[19]		未记录		未记录			0% vs 5.4%( $P$ =0.39)		0.0% vs 6.2%( $P$ =0.37)		未记录
Alcalai^[20]		未记录		未记录			0.0% vs 0.0%		0.0% vs 0.0%		0.0% vs 0.0%
Alizadeh^[21]		0.0% vs 5.0% ( $P$ =0.030)		未记录			未记录		未记录		未记录
Gama^[22]		未记录		未记录			未记录		未记录		未记录
Cochran^[23]		未记录		未记录			0.0% vs 15.3% ( $P$ =0.192)		0.0% vs 15.3% ( $P$ =0.192)		未记录
Daher^[24]		未记录		未记录			未记录		11.8% vs 9.5%( $P$ =0.8)		未记录
Jaidka^[25]		8.3% vs 0.0% ( $P$ =0.549)		16.7% vs 16.2% ( $P$ =0.971)			未记录		0.0% vs 5.4% ( $P$ =0.411)		未记录
Yunis^[26]		未记录		未记录			未记录		6个月:0.0% vs 1.1% ( $P$ =0.44) 12个月:5.3% vs 4.1% ( $P$ =0.53) 24个月:12.4% vs 5.4% ( $P$ =0.09)		未记录

表1 纳入研究的基本情况

Tab. 1 Characteristics of included studies of the meta-analysis

作者	发表年份		研究类型		随访年限	LVT的原因		DOAC vs VKA		LVT的消失率 (DOAC vs VKA)
Herald^[2]	2022		回顾性队列研究		中位数:3.4年	未记录		134 vs 299		未记录		27.6% vs 37.8%[ $H R$ :0.59(0.40-0.87), $P$ =0.007]
Zhang^[3]	2022		单中心,回顾性研究		24个月	STEMI-PCI术后		33 vs 31		6个月:42.4% vs 19.4% [ $H R$ :3.0(1.0-8.97)]; 12个月:69.7% vs 48.4%[ $H R$ :2.13(1.02-4.46)]; 18个月:78.8% vs 64.5%[ $H R$ :1.96(1.01-3.79)];24个月:78.8% vs 74.2%[ $H R$ :1.70(0.90-3.22)]		6.1% vs 9.7%[ $H R$ :0.48(0.73-3.20)]
Tamimi^[4]	2022		单中心,回顾性研究		6个月	131例患者(66.4%)有缺血性心肌病,其他患者不详		48 vs 116		66.6% vs 79.3% ( $P$ =0.08)		10.0% vs 8.0% ( $P$ =0.768)
Aldaas^[5]	2022		单中心,回顾性研究		中位数:7.2个月(新型口服抗凝药),10个月(华法林)	未记录		76 vs 146		13.2% vs 16.4%[HR 0.08(95% $C I$ : 0.00-2.57); $P$ =0.154]		未记录
Varwan^[6]	2021		单中心,回顾性研究		2年	心肌梗死(28%),慢性缺血性心肌病(42%),非缺血性心肌病(30%)		58 vs 34		55.6% vs 64.0% ( $P$ =0.51)		5.2% vs 5.9% ( $P$ =1.0)
Jones^[7]	2020		单中心、观察性、前瞻性研究		中位数:2.2年	心肌梗死		41 vs 60		151天:70.7% vs 48.3% ( $P$ =0.04) 1年: 82.0% vs 64.4% ( $P$ =0.0018) 利伐沙班、阿哌沙班和依度沙班的LVT消失率:88%, 93%, 100%		14.6% vs 36.7% ( $P$ =0.318)
Albabtain^[8]	2021		单中心,回顾性研究		利伐沙班治疗的中位数:9.5个月(25%~75%的可信区间:6~32.5个月),华法林治疗的中位数:14个月(25%~75%的可信区间:3~41个月)	心肌梗死,扩张型心肌病,心力衰竭		28 vs 35		71.4% vs 68.6% LVT消失的中位时间: 3(2~11.5)个月vs 9 (4~20)个月( $P$ =0.019)		7.1% vs 2.9% ( $P$ =0.23)
Mihm^[9]	2021		单中心,回顾性队列研究		6个月	心肌梗死,心肌病,心力衰竭,瓣膜性心脏病		33 vs 75		58.3% vs 65%		15.2% vs 2.7% ( $P$ =0.027)
Xu^[10]	2021		单中心,回顾性队列研究		2.37±2.1年 vs 2.24±2.5年	未记录		25 vs 62		76.0% vs 74.2% ( $P$ =0.057)		4.0% vs 3.2% ( $P$ =0.858)
Bass^[11]	2021		多中心,回顾性队列研究		90 d	未记录		180 vs 769		未记录		7.8% vs 10.9% ( $P$ =0.20)
Abdelnabi^[12]	2021		多中心、开放性、前瞻性、随机临床试验		未记录	未记录		39 vs 40		1个月 :71.8% vs 47.5% ( $P$ =0.03); 3个月:76.9% vs 67.5%( $P$ =0.35); 6个月:87.2% vs 80.0%( $P$ =0.39)		5.1% vs 15% ( $P$ =0.11)
Alcalai^[13]	2021		多中心、开放性、前瞻性、随机临床试验		3个月	心肌梗死后		17 vs 15		94.1% vs 93.3%		0.0%vs 13.3%
Guddeti^[14]	2020		多中心、回顾性研究		随访中位数:1年,平均随访时间: 10.4±3.4 个月	缺血性心肌病和非缺血性心肌病		19 vs 80		80.0% vs 81.0% ( $P$ =0.9)		5.3% vs 5.0%( $P$ =0.96)
Robinson^[15]	2020		多中心、队列研究		随访中位数:351 天	缺血性心肌病和非缺血性心肌病		121 vs 236		NR		6.6% vs 8.1%
Ratnayake^[16]	2020		单中心、回顾性、观察性、队列研究		6个月	ST段抬高型心肌梗死		2 vs 42		50.0% vs 81.0%		未记录
Iqbal^[17]	2020		单中心、回顾性、观察性、队列研究		评价随访时间: 3.0±1.4年	缺血性心肌病、扩张型心肌病、肥厚性心肌病、病因不详		22 vs 62		65.0% vs 76.0% ( $P$ =0.33)		0.0% vs 10.0% ( $P$ =0.13)
Ali^[18]	2020		单中心、回顾性研究		1年	慢性缺血性心肌病(58%),非缺血性心肌病(23%)		32 vs 60		56.3% vs 62.0% ( $P$ =0.85)		0.0% vs 3.3%
Willeford^[19]	2021		单中心、回顾性研究		1年	心肌梗死,心力衰竭,冠心病		22 vs 129		59.1% vs 48.8% ( $P$ =0.37)		4.5% vs 3.9% ( $P$ =1)
Alcalai^[20]	2021		多中心、开放性、前瞻性、随机临床试验		3个月	心肌梗死		13 vs 12		92.3% vs 100%		0.0% vs 16.7%
Alizadeh^[21]	2019		前瞻性、观察性研究		中位数:1.8年	心肌梗死		38 vs 60		75.0% vs 53.0% ( $P$ =0.0018)		0.0% vs 5.0% ( $P$ =0.030)
Gama^[22]	2019		单中心、回顾性、队列研究		未记录	心肌梗死,射血分数减低的心力衰竭		12 vs 52		91.7% vs 59.6%		未记录
Cochran^[23]	2021		回顾性研究		12个月	未记录		14 vs 59		76.3% vs 85.7% ( $P$ =0.721)		14.3% vs 13.65 ( $P$ =1)
Daher^[24]	2020		观察性、回顾性研究		3个月	心肌梗死,缺血性心肌病		17 vs 42		70.6% vs 71.4%( $P$ =0.9)		未记录
Jaidka^[25]	2018		回顾性研究		6个月	心肌梗死		12 vs 37		88.9% vs 69.2% ( $P$ =0.245)		25.0% vs16.2%
Yunis^[26]	2020		回顾性队列研究		24个月	未记录		64 vs 200		97.0% vs 100.0%( $P$ =0.4)		6个月:3.2% vs 1.5%( $P$ =0.46) 12个月:5.1% vs 2.1%( $P$ =0.88) 24个月:5.1% vs 4.9%( $P$ =0.12)
作者		严重出血事件 (DOAC vs VKA)		轻微出血事件 (DOAC vs VKA)			脑卒中 (DOAC vs VKA)		全身栓塞事件 (DOAC vs VKA)		全因死亡率 (DOAC vs VKA)
Herald^[2]		未记录		未记录			19.4% vs 24.4%[ $H R$ :0.75(0.48-1.19), $P$ =0.22]		21.6% vs 28.1%[ $H R$ :0.65(0.42-1.02), $P$ =0.59]		23.9% vs 46.2%[ $H R$ :0.48(0.32-0.74), $P$ =0.0008]
Zhang^[3]		24个月:0.0% vs 3.2%		24个月:6.0% vs 6.4%			未记录		24个月:3.0% vs 12.9%[ $H R$ :0.29(0.02-3.13)]		24个月:3.0% vs 12.9%[ $H R$ :0.226(0.02-2.62)]
Tamimi^[4]		未记录		未记录			未记录		未记录		未记录
Aldaas^[5]		未记录		未记录			未记录		未记录		未记录
Varwan^[6]		未记录		未记录			1.7% vs 2.9%( $P$ =1.0)		1.7% vs 2.9%( $P$ =1.0)		未记录
Jones^[7]		未记录		未记录			2.4% vs 5%( $P$ =0.388)		2.4% vs 5%( $P$ =0.388)		0.0% vs 0.0%
Albabtain^[8]		未记录		未记录			3.8% vs 2.9%( $P$ =0.99)		3.8% vs 0.0%		7.14% vs 8.57%( $P$ =0.64)
Mihm^[9]		15.2% vs 2.7% ( $P$ =0.027)		未记录			6.1% vs 5.3%		9.1% vs 5.4%		12.1% vs 8%
Xu^[10]		未记录		未记录			4.0% vs 4.8% ( $P$ =0.158)		4.0% vs 6.5% ( $P$ =0.657)		8.0% vs 4.8% ( $P$ =0.566)
Bass^[11]		未记录		未记录			7.8% vs 11.7% ( $P$ =0.13)		33.0% vs 30.6% ( $P$ =0.53)		未记录
Abdelnabi^[12]		5.1% vs 15% ( $P$ =0.11)		未记录			0.0% vs 10.0% ( $P$ =0.08)		0.0%vs 15.0% ( $P$ =0.01)		未记录
Alcalai^[13]		0.0% vs 13.3%		未记录			未记录		0.0% vs 6.7%		5.9% vs 0.0%
Guddeti^[14]		未记录		未记录			0.0% vs 2.5%( $P$ =0.49)		0.0% vs 2.5%( $P$ =0.49)		未记录
Robinson^[15]		未记录		未记录			未记录		14.0% vs 5.9%( $P$ =0.01)		11.6% vs 13.6%
Ratnayake^[16]		未记录		未记录			未记录		未记录		未记录
Iqbal^[17]		未记录		未记录			0.0% vs 2.0%( $P$ =0.55)		0.0% vs 4.0%( $P$ =0.55)		14.0% vs 10.0%( $P$ =0.61)
Ali^[18]		未记录		未记录			2 vs 7		6.7% vs 20%		未记录
Willeford^[19]		未记录		未记录			0% vs 5.4%( $P$ =0.39)		0.0% vs 6.2%( $P$ =0.37)		未记录
Alcalai^[20]		未记录		未记录			0.0% vs 0.0%		0.0% vs 0.0%		0.0% vs 0.0%
Alizadeh^[21]		0.0% vs 5.0% ( $P$ =0.030)		未记录			未记录		未记录		未记录
Gama^[22]		未记录		未记录			未记录		未记录		未记录
Cochran^[23]		未记录		未记录			0.0% vs 15.3% ( $P$ =0.192)		0.0% vs 15.3% ( $P$ =0.192)		未记录
Daher^[24]		未记录		未记录			未记录		11.8% vs 9.5%( $P$ =0.8)		未记录
Jaidka^[25]		8.3% vs 0.0% ( $P$ =0.549)		16.7% vs 16.2% ( $P$ =0.971)			未记录		0.0% vs 5.4% ( $P$ =0.411)		未记录
Yunis^[26]		未记录		未记录			未记录		6个月:0.0% vs 1.1% ( $P$ =0.44) 12个月:5.3% vs 4.1% ( $P$ =0.53) 24个月:12.4% vs 5.4% ( $P$ =0.09)		未记录

表2 DOAC与VKA治疗LVT血栓的meta分析结果

Tab. 2 The meta-analysis results of DOAC versus VKA in the treatment of LVT

	DOAC(%)	VKA(%)	$O R$ (95% $C I$ )
出血事件发生率	9.69	12.57	0.71(0.55-0.91)
卒中事件发生率	7.43	11.42	0.66(0.47-0.93)
LVT消失率	64.51	67.24	0.94(0.76-1.16)
严重出血事件发生率	4.65	5.43	0.89(0.41-1.03)
全身血栓栓塞事件发生率	13.74	17.37	0.97(0.77-1.22)
全因死亡率	13.85	23.10	0.57(0.41-0.79)

表2 DOAC与VKA治疗LVT血栓的meta分析结果

Tab. 2 The meta-analysis results of DOAC versus VKA in the treatment of LVT

	DOAC(%)	VKA(%)	$O R$ (95% $C I$ )
出血事件发生率	9.69	12.57	0.71(0.55-0.91)
卒中事件发生率	7.43	11.42	0.66(0.47-0.93)
LVT消失率	64.51	67.24	0.94(0.76-1.16)
严重出血事件发生率	4.65	5.43	0.89(0.41-1.03)
全身血栓栓塞事件发生率	13.74	17.37	0.97(0.77-1.22)
全因死亡率	13.85	23.10	0.57(0.41-0.79)

图2 出血事件发生率的meta分析

Fig. 2 Bleeding events rate forest plot

图3 卒中发生率的meta分析

Fig. 3 Stroke rate forest plot

图4 LVT消失率的meta分析

Fig. 4 LVT disappearance rate forest plot

图5 严重出血事件发生率的meta分析

Fig. 5 Major bleeding events rate forest plot

图6 全身栓塞事件发生率的meta分析

Fig. 6 Systemic embolism events rate forest plot

图7 全因死亡率的meta分析

Fig. 7 All-cause mortality rate forest plot

表3 LVT的溶栓治疗

Tab. 3 Thrombolytic therapy for LVT

作者	例数	溶栓药物	方法	结果
Kremer^[30]	16	尿激酶	60.000 U/h输注×2~8天,静脉应用肝素200 U/kg×12 h;溶栓结束后给予双香豆素持续抗凝。应用普通经胸超声心动图对血栓进行评估	10例患者血栓完全消失,4例患者血栓减小,2例患者血栓无明显变化。溶栓治疗过程中,无患者发生全身血栓栓塞事件,有2例患者发生血尿,其中1例患者因此停止溶栓治疗。6个月后应用超声心动图进行随访,血栓完全消失的患者未新发血栓
Yeh^[31]	1	rt-PA	rt-PA 15 mg负荷量,随后30分钟内给予50 mg静脉输注,其后1小时内给予35 mg静脉输注;输注完成后静脉应用肝素维持活化凝血酶原时间为正常值的1.5~2倍。后续华法林持续抗凝	溶栓完成后2、4、16、40 h超声心动图示血栓逐渐减小最终消失,治疗过程中无出血或者全身栓塞事件等并发症发生

表4 LVT的抗血小板治疗

Tab. 4 Anti-platelet therapy for LVT

作者	例数	药物及用药方法	结果
Kouvaras^[32]	60	60例继发心肌梗死的LVT患者随机均分为抗凝组(口服抗凝药治疗,凝血酶原时间延长至1.6~2倍)、抗血小板组(阿司匹林 650 mg/d)及对照组(未给予任何抗栓治疗)。应用超声心动图每3个月进行1次随访,共随访9~24个月(平均16±5个月)	3个月后随访发现:抗凝组12例患者血栓消失,3例患者血栓明显减小;抗血小板组9例患者血栓消失,4例患者血栓明显减小;对照组2例患者血栓消失。抗凝组与抗血小板组的血栓消失率与血栓减小率相当;而对照组血栓自发消失率及血栓减小率很低
Kupferschmid^[33]	3	3例扩张型心肌病患者。第1例应用阿司匹林(25 mg/kg)和双嘧达莫(6 mg/kg);第2例应用阿司匹林和双嘧达莫(具体剂量不详);第3例应用抗血小板治疗(具体不详)	虽然治疗过程中,LVT消失,但在继续抗血小板治疗的随访过程中,LVT再次出现,提示单独抗血小板治疗对于治疗LVT无效
Stratton^[34]	16	将16例主要继发于陈旧性心肌梗死的LVT患者分为苯磺唑酮组(200 mg, 4次/d;7人次),阿司匹林联合双嘧达莫组(阿司匹林325 mg,1次/d,双嘧达莫75 mg, 3次/d ;6人次), 全剂量华法林组(4人次)	应用铟-111血小板成像和超声心动图进行随访,苯磺唑酮组中铟-111血小板成像:3例患者转阴,2例变得模糊,2例无任何变化;超声心动图发现7例患者血栓大小无变化。阿司匹林联合双嘧达莫组铟-111血小板成像:1例患者患者转阴,3例变得模糊,2例无任何变化;超声心动图发现1例患者血栓减小,6例患者血栓大小无变化。华法林组:铟-111血小板成像:3例患者患者转阴,1例无任何变化;超声心动图发现1例血栓减小,2例血栓大小无变化。发现与应用抗凝剂相比,联合应用抗血小板药物(阿司匹林、双嘧达莫)可以抑制血小板在LVT表面聚集,但无法使血栓消失或变小
Bellotti^[35]	32	32例继发于陈旧性心肌梗死的LVT患者分为噻氯匹定组(6例患者250 mg, 1次/d,5例患者 500 mg/d),吲哚布芬组(12例患者:400 mg/d),未治疗组(9例患者)	(40±11) d后,In-oxine血小板成像检查:噻氯匹定组2例(500 mg/d)血小板沉积完全消失,5例(2例:500 mg/d,3例:250 mg/d)血小板沉积减少;吲哚布芬组5例和未治疗组1例血小板沉积减少。超声心动图检查:只有噻氯匹定组1例(25 0mg 1/日)血栓减小。结果表明应用抗血小板药物(吲哚布芬、噻氯匹定)虽可抑制血小板在血栓表面聚集,但无助于血栓的缩小或消失

表4 LVT的抗血小板治疗

Tab. 4 Anti-platelet therapy for LVT

作者	例数	药物及用药方法	结果
Kouvaras^[32]	60	60例继发心肌梗死的LVT患者随机均分为抗凝组(口服抗凝药治疗,凝血酶原时间延长至1.6~2倍)、抗血小板组(阿司匹林 650 mg/d)及对照组(未给予任何抗栓治疗)。应用超声心动图每3个月进行1次随访,共随访9~24个月(平均16±5个月)	3个月后随访发现:抗凝组12例患者血栓消失,3例患者血栓明显减小;抗血小板组9例患者血栓消失,4例患者血栓明显减小;对照组2例患者血栓消失。抗凝组与抗血小板组的血栓消失率与血栓减小率相当;而对照组血栓自发消失率及血栓减小率很低
Kupferschmid^[33]	3	3例扩张型心肌病患者。第1例应用阿司匹林(25 mg/kg)和双嘧达莫(6 mg/kg);第2例应用阿司匹林和双嘧达莫(具体剂量不详);第3例应用抗血小板治疗(具体不详)	虽然治疗过程中,LVT消失,但在继续抗血小板治疗的随访过程中,LVT再次出现,提示单独抗血小板治疗对于治疗LVT无效
Stratton^[34]	16	将16例主要继发于陈旧性心肌梗死的LVT患者分为苯磺唑酮组(200 mg, 4次/d;7人次),阿司匹林联合双嘧达莫组(阿司匹林325 mg,1次/d,双嘧达莫75 mg, 3次/d ;6人次), 全剂量华法林组(4人次)	应用铟-111血小板成像和超声心动图进行随访,苯磺唑酮组中铟-111血小板成像:3例患者转阴,2例变得模糊,2例无任何变化;超声心动图发现7例患者血栓大小无变化。阿司匹林联合双嘧达莫组铟-111血小板成像:1例患者患者转阴,3例变得模糊,2例无任何变化;超声心动图发现1例患者血栓减小,6例患者血栓大小无变化。华法林组:铟-111血小板成像:3例患者患者转阴,1例无任何变化;超声心动图发现1例血栓减小,2例血栓大小无变化。发现与应用抗凝剂相比,联合应用抗血小板药物(阿司匹林、双嘧达莫)可以抑制血小板在LVT表面聚集,但无法使血栓消失或变小
Bellotti^[35]	32	32例继发于陈旧性心肌梗死的LVT患者分为噻氯匹定组(6例患者250 mg, 1次/d,5例患者 500 mg/d),吲哚布芬组(12例患者:400 mg/d),未治疗组(9例患者)	(40±11) d后,In-oxine血小板成像检查:噻氯匹定组2例(500 mg/d)血小板沉积完全消失,5例(2例:500 mg/d,3例:250 mg/d)血小板沉积减少;吲哚布芬组5例和未治疗组1例血小板沉积减少。超声心动图检查:只有噻氯匹定组1例(25 0mg 1/日)血栓减小。结果表明应用抗血小板药物(吲哚布芬、噻氯匹定)虽可抑制血小板在血栓表面聚集,但无助于血栓的缩小或消失

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