超越心房颤动：风湿性心脏病的临床与超声心动图预测缺血性卒中及系统性血栓栓塞：系统综述与荟萃分析。
完整摘要 · 中文译文
目的：心房颤动（AF）是风湿性心脏病（RHD）中最确立的血栓栓塞危险因素，但卒中和血栓栓塞亦可发生在无房颤记录的患者中。我们系统整合了RHD中非房颤的临床/超声心动图预测因子与血栓栓塞之间的关联，并比较了房颤校正估计值与未校正估计值。 方法：检索了PubMed/MEDLINE、Embase、Scopus和Web of Science，并辅以Google Scholar和引文筛查。符合条件的研究评估了具有≥1个非房颤卒中或血栓栓塞预测因子的RHD患者。两名 reviewers 进行了筛选、数据提取和QUIPS偏倚风险评估；证据确定性采用GRADE分级。分别提取未校正、校正及房颤校正的估计值，并在可行时进行随机效应荟萃分析。 结果：十九项研究（约8，206例患者）符合入选标准。SEC、左房大小/容积、左房/心耳血栓、左房心耳血流、左房机械功能、二尖瓣严重程度、年龄和既往血栓栓塞是最常被检验的预测因子。四项研究提供了可比较的SEC粗比值比（合并OR 8.27，95% CI 3.21-21.29；I² = 66%），在校正房颤后显著减弱（低至OR 1.7，95% CI 1.1-3.0）。在包含房颤的模型中，年龄较大和既往卒中仍与血栓栓塞相关，而左房机械/储存功能显示出一致的反向关联，包括在窦性心律下亦然。SEC、年龄和左房功能的证据确定性为低；既往卒中/血栓栓塞为中等；未使用抗凝治疗为极低。 结论 在风湿性心脏病（RHD）中，血栓栓塞风险不仅限于已证实的房颤（AF）。自发超声显影（SEC）显示出最强的未调整关联，但在调整AF后其关联性显著减弱，这可能部分反映了亚临床AF的存在；SEC依赖于经食管超声心动图（TEE）且分级标准不一致。在包含AF的调整后，高龄、既往血栓栓塞史以及左心房（LA）机械/储存功能受损显示出更为持续的关联；这些发现需要前瞻性验证。
完整摘要 · 英文原文
PURPOSE: Atrial fibrillation (AF) is the best-established thromboembolic risk factor in rheumatic heart disease (RHD), but stroke and thromboembolism also occur without documented AF. We systematically synthesised associations between non-AF clinical/echocardiographic predictors and thromboembolism in RHD, comparing AF-adjusted with unadjusted estimates. METHODS: PubMed/MEDLINE, Embase, Scopus, and Web of Science were searched, supplemented by Google Scholar and citation screening. Eligible studies evaluated RHD patients with ≥1 non-AF predictor of stroke or thromboembolism. Two reviewers performed selection, extraction, and QUIPS risk-of-bias assessment; certainty was graded using GRADE. Unadjusted, adjusted, and AF-adjusted estimates were extracted separately, and random-effects meta-analysis was performed when feasible. RESULTS: Nineteen studies (∼8,206 patients) met eligibility criteria. SEC, LA size/volume, LA/appendage thrombus, LA appendage flow, LA mechanical function, mitral valve severity, age, and previous thromboembolism were most frequently examined. Four studies provided comparable crude ORs for SEC (pooled OR 8.27, 95% CI 3.21-21.29; I2 = 66%), substantially attenuated after AF adjustment (as low as OR 1.7, 95% CI 1.1-3.0). Older age and previous stroke remained associated with thromboembolism in AF-inclusive models, and LA mechanical/reservoir function showed consistent inverse associations, including in sinus rhythm. Certainty was low for SEC, age, and LA function; moderate for previous stroke/thromboembolism; very low for anticoagulation non-use. CONCLUSION: In RHD, thromboembolic risk extends beyond documented AF. SEC showed the strongest unadjusted association but was substantially attenuated after AF adjustment, likely partly reflecting subclinical AF; it is TEE-dependent and inconsistently graded. Older age, previous thromboembolism, and impaired LA mechanical/reservoir function showed more persistent associations after AF-inclusive adjustment; prospective validation is needed.