Meta-Analysis Investigating the Role of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi

Left ventricular thrombus (LVT) is a well-recognized complication of left ventricular systolic dysfunction, especially in the setting of acute myocardial infarction. It results from the presence of factors that represent Virchow's triad in the ventricle – reduced wall motion, local myocardial injury, and hypercoagulability/stasis of blood flow. In the pre-reperfusion era, the incidence of LVT was reported to be as high as 40 percent in patients with anterior infarction. However, given the widespread availability of primary percutaneous coronary interventions and the improvements in adjunctive medical therapies, the incidence of LVT has decreased significantly. Vitamin K antagonists (VKAs) were the gold standard in treating LVT for decades. Until recently, after the success of direct oral anticoagulants (DOACs) in atrial fibrillation and deep vein thrombosis, many providers are using DOACs in the management of LVT. A recent study showed that 43.9% of patients diagnosed with LVT were on off-label DOACs. Additionally, over the past decade, several case reports and series reported good outcomes with DOACs. ^, More recently, multiple retrospective studies supported the role of DOACs in patients with LVT. Finally, a randomized control trial showed faster thrombus resolution with Rivaroxaban in comparison to warfarin. Given that several recent studies were published, we conducted a meta-analysis to evaluate the role of DOACs versus warfarin in patients with LVT.