Current guidelines recommend vitamin K antagonists (VKAs) for the treatment of a left
ventricular thrombus (LVT). However, direct oral anticoagulants (DOACs) show superior
safety and efficacy compared with VKAs in most thromboembolic disorders. Nevertheless,
DOACs remain poorly investigated for the treatment of LVT. To describe the thrombus
resolution rate and clinical efficacy of DOACs versus VKAs in patients with LVT, we
analyzed consecutive patients with confirmed LVT from a multicenter echocardiography
database. Echocardiograms and clinical end points were evaluated independently. The
thrombus resolution rate and clinical outcomes were compared according to the underlying
anticoagulation regimen. In total, 101 patients were included (17.8% women, mean age
63.3 ± 13.2 years), 50.5% had recently experienced a myocardial infarction. The mean
left ventricular ejection fraction was 36.6 ± 12.2%. DOACs versus VKAs were used in
48 and 53 patients, respectively. The median follow-up was 26.6 (interquartile range
11.8;41.2) months. Among patients receiving VKAs compared with DOACs, the thrombus
resolved more rapidly within the first month in those taking VKAs (p = 0.049). No
differences were seen between the 2 groups with respect to major bleedings, strokes,
and other thromboembolic events. In each group, LVT recurred in 3 of the subjects
(a total of 6) after discontinuation of anticoagulation. In conclusion, DOACs appear
to be a safe and effective alternative to VKAs for the treatment of LVTs, but the
rate of thrombus dissolution within 1 month after initiation of anticoagulation appears
to be higher with VKAs. A sufficiently powered randomized trial is required to definitively
define the role of DOACs in the treatment of LVT.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy.Am J Cardiol. 2010; 106: 1197-1200
- 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2018; 39: 119-177
- Executive summary: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published correction appears in Chest 2012;141:1129. Dosage error in article text] [published correction appears in Chest 2012;142:1698. Dosage error in article text].Chest. 2012; 141: 7S-47S
- American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Management of patients at risk for and with left ventricular thrombus: A scientific statement from the American Heart Association.Circulation. 2022; 146: e205-e223
- ENGAGE AF-TIMI 48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2013; 369: 2093-2104
- Wallentin L; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2011; 365: 981-992
- Oral Rivaroxaban for the treatment of symptomatic pulmonary embolism.N Engl J Med. 2012; 366: 1287-1297
- Left ventricular thrombus formation after acute myocardial infarction.Heart. 2012; 98: 1743-1749
- Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Investigators. Patients’ time in therapeutic range on warfarin among US patients with atrial fibrillation: results from ORBIT-AF registry.Am Heart J. 2015; 170: 141-148.e1.
- Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi.JAMA Cardiol. 2020; 5: 685-692
- Wallentin L; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151
- Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation.N Engl J Med. 2019; 380: 1509-1524
- The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction.Eur Heart J Cardiovasc Pharmacother. 2021; 7: 398-404
- Direct oral anticoagulant use in left ventricular thrombus.Thromb J. 2020; 18: 29
- Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus.ESC Heart Fail. 2020; 7: 2032-2041
- Direct oral anticoagulants versus warfarin in the treatment of left ventricular thrombus.Ann Pharmacother. 2021; 55: 839-845
- Direct oral anticoagulants in the treatment of left ventricular thrombus: A retrospective, multicenter study and meta-analysis of existing data.J Cardiovasc Pharmacol Ther. 2021; 26: 173-178
- Treatment of left ventricular thrombus with direct oral anticoagulants: A retrospective observational study.Am J Med. 2020; 133: 1488-1491
- Incidence of left ventricular thrombus in patients with acute ST-segment elevation myocardial infarction treated with percutaneous coronary intervention.Am J Cardiol. 2018; 121: 27-31
- Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus.J Thromb Thrombolysis. 2021; 52: 517-522
- The multiple faces of heparin: opportunities in COVID-19 infection and beyond.Thromb Haemost. 2020; 120: 1347-1350
- Treatment of proximal deep-vein thrombosis with the oral direct factor Xa inhibitor rivaroxaban (BAY 59-7939): the ODIXa-DVT (Oral Direct Factor Xa Inhibitor BAY 59-7939 in Patients With Acute Symptomatic Deep-Vein Thrombosis) study.Circulation. 2007; 116: 180-187
- Rivaroxaban: population pharmacokinetic analyses in patients treated for acute deep-vein thrombosis and exposure simulations in patients with atrial fibrillation treated for stroke prevention [published correction appears in Clin Pharmacokinet 2012;51:136].Clin Pharmacokinet. 2011; 50: 675-686
- Major bleeding rates in atrial fibrillation patients on single, dual, or triple antithrombotic therapy.Circulation. 2019; 139: 775-786
- Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention.J Am Coll Cardiol. 2013; 62: 981-989
- Antithrombotic therapy for patients with left ventricular mural thrombus.J Am Coll Cardiol. 2020; 75: 1676-1685
- Use of direct oral anticoagulants in the treatment of left ventricular thrombi: A systematic review.Am J Med. 2020; 133: 1266-1273.e6
- Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge.Eur Heart J Qual Care Clin Outcomes. 2022; 8: 496-509
- Embolic potential of left ventricular thrombus after myocardial infarction: a two-dimensional echocardiographic study of 119 patients.J Am Coll Cardiol. 1985; 5: 1276-1280
- Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: A serial cardiac MRI study.Int J Cardiol Heart Vasc. 2019; 24100395
Article info
Publication history
Published online: February 25, 2023
Received in revised form:
January 5,
2023
Received:
December 7,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Thomas Seiler and Egle Vasiliauskaite, contributed equally to this manuscript and share the first authorship.
Richard Kobza and Matthias Bossard contributed equally to this manuscript and share the senior authorship.
Funding: none.
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
