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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.
      • Nihoyannopoulos P
      • Smith GC
      • Maseri A
      • Foale RA
      The natural history of left ventricular thrombus in myocardial infarction: a rationale in support of masterly inactivity.
      However, given the widespread availability of primary percutaneous coronary interventions and the improvements in adjunctive medical therapies, the incidence of LVT has decreased significantly.
      • Gianstefani S
      • Douiri A
      • Delithanasis I
      • Rogers T
      • Sen A
      • Kalra S
      • Charangwa L
      • Reiken J
      • Monaghan M
      • MacCarthy P.
      Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention.
      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.
      • Robinson AA
      • Trankle CR
      • Eubanks G
      • Schumann C
      • Thompson P
      • Wallace RL
      • Gottiparthi S
      • Ruth B
      • Kramer CM
      • Salerno M
      • Bilchick KC
      • Deen C
      • Kontos MC
      • Dent J
      Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi.
      Additionally, over the past decade, several case reports and series reported good outcomes with DOACs.
      • Mujer M
      • Kandola SK
      • Saleh Y.
      Rare case of biventricular thrombi complicating pulmonary embolism.
      ,
      • Abdelnaby M
      • Almaghraby A
      • Abdelkarim O
      • Saleh Y
      • Hammad B
      • Badran H
      The role of rivaroxaban in left ventricular thrombi.
      More recently, multiple retrospective studies supported the role of DOACs in patients with LVT.
      • Al-abcha A
      • Herzallah K
      • Saleh Y
      • Mujer M
      • Abdelkarim O
      • Abdelnabi M
      • Almaghraby A
      • Abela GS
      The role of direct oral anticoagulants versus vitamin K antagonists in the treatment of left ventricular thrombi: a meta-analysis and systematic review.
      Finally, a randomized control trial showed faster thrombus resolution with Rivaroxaban in comparison to warfarin.
      • Abdelnabi M
      • Saleh Y
      • Fareed A
      • Nossikof A
      • Wang L
      • Morsi M
      • Eshak N
      • Abdelkarim O
      • Badran H
      • Almaghraby A.
      Comparative study of oral anticoagulation in left ventricular thrombi (No-LVT Trial).
      Given that several recent studies were published, we conducted a meta-analysis to evaluate the role of DOACs versus warfarin in patients with LVT.
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      References

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        • Smith GC
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        • Foale RA
        The natural history of left ventricular thrombus in myocardial infarction: a rationale in support of masterly inactivity.
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        Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention.
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        Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi.
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