循環器ジャーナル68巻4号

2020年10月発行

特集 抗血栓療法—日常臨床での疑問に応える Ⅴ．周術期・その他の抗血栓療法

心内（左室内・左房内）血栓に対する抗血栓療法の注意点は？

著者： 藤野雅史¹

所属機関： ¹国立研究開発法人国立循環器病研究センター冠疾患科

ページ範囲：P.720 - P.727

Point
・予防の観点では，つまり心内血栓の既往がない症例では，左室内血栓の予防に対する抗凝固療法のエビデンスはなく，心房細動の左房内血栓に対する予防のための抗凝固療法は確立されている．
・左室内血栓に対する抗血栓治療はビタミンK拮抗薬（ワルファリン）であり，新規経口抗凝固薬（DOAC）のエビデンスは乏しい．
・左房内血栓に対する治療は確立されたものはないが，綿密な画像検査による血栓の観察下にワルファリンもしくはDOACによる抗凝固療法を行う．
・心内血栓に対する抗血栓療法については，冠動脈インターベンションに対する抗血小板薬と同様，血栓塞栓症に対する効果（efficacy）と出血に対する懸念（safety）を患者個別に考慮し，その適応を検討する必要がある．

参考文献

1) 日本循環器学会/日本心不全学会：心筋症診療ガイドライン（2018年改訂版）．2019

2) 日本循環器学会：冠動脈疾患患者における抗血栓療法．2020

3) Ibanez B, James S, Agewall S, et al:2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation:The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology（ESC）. Eur Heart J 39:119-177, 2017

4) O'Gara PT, Kushner FG, Ascheim DD, et al:2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 127:e362-425, 2013

5) Maniwa N, Fujino M, Nakai M, et al:Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J 39:201-208, 2018

6) Matsumura-Nakano Y, Shizuta S, Komasa A, et al:Open-Label Randomized Trial Comparing Oral Anticoagulation With and Without Single Antiplatelet Therapy in Patients With Atrial Fibrillation and Stable Coronary Artery Disease Beyond 1 Year After Coronary Stent Implantation. Circulation 139:604-616, 2019

7) Mega JL, Braunwald E, Wiviott SD, et al:Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med 366:9-19, 2012

8) Zannad F, Anker SD, Byra WM et al:Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease. N Engl J Med 379:1332-1342, 2018

9) Cokkinos DV, Haralabopoulos GC, Kostis JB, et al:Efficacy of antithrombotic therapy in chronic heart failure:the HELAS study. Eur J Heart Fail 8:428-432, 2006

10) Homma S, Thompson JL, Pullicino PM, et al:Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 366:1859-1869, 2012

11) Robinson AA, Trankle CR, Eubanks G, et al:Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol 5:685-692, 2020

12) 日本循環器学会/日本不整脈心電学会：不整脈薬物治療ガイドライン．2020

13) 日本循環器学会：弁膜症治療のガイドライン．2020

14) Beppu S, Park TD, Sakakibara H, et al:Clinical features of intracardiac thrombosis based on echocardiographic observation. Jpn Circ J 48:75-82, 1984

15) Lin SL, Chen CH, Hsu TL, et al:A left atrial thrombus is not an absolute limitation to balloon mitral commissurotomy for patients with mitral stenosis. a serial transesophageal echocardiographic study. Cardiology 92:145-150, 1999

16) Silaruks S, Kiatchoosakun S, Kiatchoosakun S, et al:Resolution of left atrial thrombi with anticoagulant therapy in candidates for percutaneous transvenous mitral commissurotomy. J Heart Valve Dis 11:346-352, 2002

17) Morita S, Ajiro Y, Uchida Y, et al:Dabigatran for left atrial thrombus. Eur Heart J 34:2745, 2013

18) Hammerstingl C, Pötzsch B, Nickenig G:Resolution of giant left atrial appendage thrombus with rivaroxaban. Thromb Haemost 109:583-584, 2013

19) Kawakami T, Kobayakawa H, Ohno H, et al:Resolution of left atrial appendage thrombus with apixaban. Thromb J 11:26, 2014

20) Lip GY, Hammerstingl C, Marin F, et al:Left atrial thrombus resolution in atrial fibrillation or flutter:Results of a prospective study with rivaroxaban（X-TRA）and a retrospective observational registry providing baseline data（CLOT-AF）. Am Heart J 178:126-134, 2016

21) Piotrowski R, Zaborska B, Pilichowska-Paszkiet E, et al:RIVAroxaban TWICE daily for lysis of thrombus in the left atrial appendage in patients with non-valvular atrial fibrillation:the RIVA-TWICE study. Arch Med Sci 16:289-296, 2020

22) Watanabe T, Shinoda Y, Ikeoka K, et al:Dabigatran Therapy Resulting in the Resolution of Rivaroxaban-resistant Left Atrial Appendage Thrombi in Patients with Atrial Fibrillation. Intern Med 56:1977-1980, 2017

23) Miwa Y, Minamishima T, Sato T, et al:Resolution of a warfarin and dabigatran-resistant left atrial appendage thrombus with apixaban. J Arrhythm 32:233-235, 2016

24) Collins LJ, Silverman DI, Douglas PS, et al:Cardioversion of nonrheumatic atrial fibrillation. Reduced thromboembolic complications with 4 weeks of precardioversion anticoagulation are related to atrial thrombus resolution. Circulation 92:160-163, 1995

25) Corrado G, Tadeo G, Beretta S, et al:Atrial thrombi resolution after prolonged anticoagulation in patients with atrial fibrillation. Chest 115:140-143, 1999

26) Natsuaki M, Morimoto T, Yamaji K, et al:Prediction of Thrombotic and Bleeding Events After Percutaneous Coronary Intervention:CREDO-Kyoto Thrombotic and Bleeding Risk Scores. J Am Heart Assoc 7:e008708, 2018