Тромбоз левого предсердия и/или его ушка при неклапанной фибрилляции предсердий: эхокардиографические и лабораторные факторы риска, возможности прогнозирования и коррекции

В обзоре представлены данные о возможностях использования лабораторных показателей для прогнозирования наличия тромба в левом предсердии (ЛП) и/или его ушке (уЛП) при неклапанной фибрилляции предсердий (нФП). Охарактеризована связь с наличием тромба в ЛП/уЛП группы крови, отдельных показателей периферической крови, уровней в крови мозгового натрийуретического пептида, гомоцистеина, ассиметричного Д-метиларгинина, мочевой кислоты и Д-димера.

Представлены данные исследований, продемонстрировавших связь с наличием тромба в ЛП/уЛП отдельных показателей, получаемых при трансторакальной эхокардиографии: индекса массы миокарда левого желудочка, индекса объема левого предсердия, отношения ФВЛЖ/индекс объема левого предсердия, отношения Е/e', пиковой систолической деформации левого предсердия.

Охарактеризованы возможности различных шкал в оценке вероятности наличия тромбоза ЛП/уЛП при нФП. Продемонстрирована недостаточная информативность шкал CHADS₂ и CHA₂DS₂-VASc и охарактеризованы попытки их улучшения за счет добавления других факторов риска (шкалы CHA₂DS₂-VASc-MS, CHA₂DS₂VASc-AFR, CHA₂DS₂VASc-RAF, а также возможная роль дополнительного учета концентрации мозгового натрийуретического пептида в крови). Показано, что перспективно добавление к шкале CHA₂DS₂-VASc информации о длительности пароксизма нФП и скорости клубочковой фильтрации. Кроме того, возможна польза от учета наличия метаболического синдрома. В целом наиболее успешными оказались подходы с добавлением к шкале CHA₂DS₂-VASc сведений о длительности пароксизма нФП и скорости клубочковой фильтрации.

Представлены недостатки накопленной доказательной базы о связи изученных показателей с наличием тромба ЛП/уЛП, среди которых небольшое число обследованных больных, обычно ретроспективный характер изучения, поиск тромба в ЛП/ уЛП перед планируемой катетерной аблацией или электроимпульсной терапией. В итоге неизвестно, насколько применимы изученные предикторы и шкалы к более широкому контингенту больных с нФП. Коме того, большинство исследований выполнено на азиатской популяции и неясно, можно ли экстраполировать их результаты на другие этнические группы. Показано, что как минимум у трети больных тромбы не исчезают на фоне антикоагулянтной терапии.

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