Криптогенный инсульт при фибрилляции предсердий без внутрисердечного тромба: возможные механизмы

До 45 % ишемических инсультов являются крипрогенными.

Цель – изучить, какой вариант перманентной фибриляции предсердий (ФП) без внутрисердечных тромбов является наиболее неблагоприятным в возникновении инсульта.

Методы. Под нашим наблюдением находилось 202 пациента с постоянной формой ФП без внутрисердечных тромбов и с гемодинамически незначимым атеросклеротическим стенозом каротидной бифуркации. Проводили эхокардиографию, суточное мониторирование электрокардиографии (ЭКГ), УЗИ брахиоцефальных артерий, сфигмографию общих сонных артерий, компьютерную томографию головного мозга, гемостазиограммы, липидограмму, гемоглобин А1с. По данным суточного мониторирования ЭКГ мы разделили пациентов на две группы в зависимости от максимальных пауз между желудочковыми комплексами при ФП: пациенты с паузой <1,5 с (113 человек); ≥1,5 с (89 человек). Обе группы получали одинаковую стандартную терапию, включая новые пероральные антикоагулянты. Мы наблюдали пациентов в
течение одного года для анализа верифицированного инсульта или транзиторной ишемической атаки (ТИА).
Полученные результаты. При УЗИ отмечено увеличение линейной скорости кровотока в зоне каротидного стеноза при распространении пульсовой волны после длительной паузы между сокращениями желудочков во 2-й группе до 2,5 м/с, как и при гемодинамически значимом стенозе. При однолетнем наблюдении частота инсультов была выше во 2-й группе.

Заключение. Возникновение инсульта и ТИА при ФП выше у пациентов, имеющих паузы максимальной продолжительности 1,5 с и более между сокращениями желудочков. Причиной криптогенного инсульта может быть дефрагментация атеросклеротической бляшки с последующей эмболией, обусловленная дополнительным механическим воздействием повышенных гемодинамических параметров пульсовой волны после длительной паузы между сокращениями желудочков.

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