Тромбоз левого желудочка: состояние проблемы и место прямых оральных антикоагулянтов

Тромбоз полости левого желудочка (ЛЖ) является серьезным фактором риска развития инсультов и системных эмболий. Несмотря на очевидную угрозу такого состояния, ведение пациентов с этим потенциально фатальным осложнением отражено в современных рекомендациях недостаточно. Тромб в полости ЛЖ встречается как осложнение при инфаркте миокарда, где частота его формирования составляет около 10%, а также при различных формах кардиомиопатий и новой коронавирусной инфекции. По данным клинических рекомендаций, для резолюции тромба препаратами выбора являются антагонисты витамина К (АВК). Однако эксперты отмечают, что данная терапия не имеет под собой необходимой доказательной базы, а также сопряжено с трудностями из-за фармакокинетических и фармакодинамических особенностей АВК. Этих недостатков лишены прямые оральные антикоагулянты (ПОАК), возможность использования которых при тромбозе ЛЖ активно изучается. На текущий момент опубликованы результаты 3 рандомизированных клинических исследований, которые показали схожий профиль безопасности и эффективности у ПОАК и АВК. Подавляющее большинство ретроспективных когортных исследований также не выявили значимых различий между двумя группами препаратов, а в некоторых было выявлено превосходство ПОАК, в особенности, по скорости резолюции тромба. Однако встречаются и сообщения о неэффективности и даже потенциальной небезопасности ПОАК в данной клинической ситуации. Существующий объем данных не позволяет сформировать однозначный вывод о равнозначности ПОАК и АВК при резолюции тромбоза ЛЖ. Существует необходимость в проведении более масштабных рандомизированных клинических исследований для определения эффективности и безопасности применения данной группы препаратов у таких пациентов.

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