Aims Current guidelines recommend anticoagulation with a vitamin K antagonist to treat left ventricular (LV) thrombus post myocardial infarction (MI). Data on the use of direct oral anticoagulants (DOACS) in this setting is limited. The aim of the study was to assess the efficacy of apixaban versus warfarin in treating LV thrombus after MI. Methods and results A prospective, randomized, multi-center open label clinical trial including patients with LV thrombus detected by 2D-transthoracic-echocardiography 1–14 days after acute MI. Thirty-five patients were enrolled in 3 medical centers, 17 patients were randomized to warfarin and 18 patients to apixaban. The primary outcome was the presence and size of LV thrombus 3 months after initiation of anticoagulation. Secondary outcomes were major bleeding, stroke or systemic embolism, re-hospitalization, and all-cause mortality. Mean LV thrombus size at enrollment was 18.5 × 12.3 mm in the warfarin group and 19.9 × 12.4 mm in the apixaban group (P = NS). Thirty-two patients completed 3 months follow-up. In the warfarin group two patients withdrew and in the apixaban group one patient died. Thrombus completely resolved in 14 of 15 patients in the warfarin group and in 16 of 17 in the apixaban group ((P = NS, P = 0.026 for non-inferiority). Two patients had major bleeding in the warfarin group while no major bleeding events were recorded in the apixaban group. There was one stroke in the warfarin group and one death in the apixaban group. Conclusion Our results suggest that apixaban is non-inferior to warfarin for treatment of patients with LV thrombus after acute MI with a 20% non-inferiority margin.

Background: Hemoglobin (Hb) is a standard and widely available clinical parameter that predicts clinical outcomes in heart failure (HF) patients. Red cell distribution width (RDW) is also a routinely measured clinical parameter that is predictive of clinical outcomes in HF. The ratio between Hb and RDW has yet to be evaluated in HF. Methods: We evaluated the predictive value of the Hb/RDW ratio on clinical outcomes in patients with HF. All patients diagnosed with chronic HF at a health maintenance organization were evaluated for Hb/RDW ratio and followed for cardiac-related hospitalizations and death. Results: The study cohort included 6888 HF patients. The mean Hb/RDW ratio was 0.85 ± 0.18; median was 0.85 (interquartile range 0.72–0.98). Patients with a lower Hb/RDW ratio were more likely to be women and had more comorbidities. The overall two year-mortality rate was 23.2%. Decreasing quantiles of the Hb/RDW ratio were associated with reduced survival rates and reduced event-free survival from death or cardiovascular-hospitalizations. Multivariable Cox regression analysis after adjustment for significant predictors demonstrated that low Hb/RDW ratio was a significant predictor of mortality, with a graded increased risk as Hb/RDW ratio decreased. Lower Hb/RDW ratio was also a significant independent predictor of the combined endpoint of death or cardiovascular hospitalizations. A sensitivity analysis evaluating Hb/RDW ratio as a continuous parameter using restricted cubic splines demonstrated a continuous increase in the mortality risk with decreasing Hb/RDW ratio, p < 0.0001 for the linear model. Conclusions: Hb/RDW ratio is a significant prognostic tool for predicting HF mortality and cardiovascular hospitalizations.

The role of percutaneous mitral valve repair (PMVr) in management of high-risk patients with severe mitral regurgitation (MR) and acute decompensated heart failure (ADHF) is undetermined. We screened all patients who underwent PMVr between October 2015 and March 2020. We evaluated immediate, 30-day, and 1-year outcomes in patients who underwent PMVr during hospitalization due to ADHF as compared to elective patients. From a cohort of 237 patients, we identified 46 patients (19.4%) with severe MR of either functional or degenerative etiology who underwent PMVr during index hospitalization due to ADHF, including 17 (37%) critically ill patients. Patients’ mean age was 75.2 ± 9.8 years, 56% were males. There were no differences in background history between ADHF and elective patients. Patients with ADHF were at higher risk for surgery, reflected in higher mean EuroSCORE II, compared with elective patients. After PMVr, we observed higher 30-day mortality rate in ADHF patients as compared to the elective group (10.9% vs. 3.1%, respectively, p = 0.042). One-year mortality rate was similar between the groups (21.7% vs. 17.9%, p = 0.493). Clinical and echocardiographic follow-up showed improvement of NYHA functional class and sPAP reduction in both groups ((54 ± 15 mmHg to 50 ±15 in the elective group (p = 0.02), 58 ± 13 mmHg to 52 ± 12 in the ADHF group (p = 0.02)). PMVr could be an alternative option for treatment of patients with severe MR and ADHF.