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Background: Left ventricular thrombus(LVT) can lead to serious complications, and mostly formed after ST-Elevation myocardial infarction(STEMI). The Off-label use of new oral anticoagulants(NOACs) in the triple therapy of LVT after STEMI has increased in the past few years. As one of the most widely used NOACs, the data of safety and efficacy of rivaroxaban in LVT after STEMI is limited and warrants continued exploring.Methods: We conducted a retrospective cohort study involving STEMI patients underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we evaluated the efficacy and safety of rivaroxaban plus DAPT therapy associated with thrombus resolution and clinical adverse events, compared with triple therapy with VKA. Results: In 1,335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period[HR:1.57(95%CI 0.89-2.77), p=0.096; Adjusted HR:1.70(95%CI 0.90-3.22), p=0.104]. When the analysis focused on LVT resolution at different time points during the follow-up period, triple therapy with rivaroxaban showed quicker resolution than with VKA(6months:p=0.049; 12months:p=0.044; 18months:p=0.045). Meanwhile, similar risks of ISTH bleeding were recorded in both groups, with no difference between the two groups(Rivaroxaban 6.1% vs VKA 9.7% , p=0.444). Fewer net adverse clinical events(NACE) were observed in the rivaroxaban group compared with the VKA group[Rivaroxaban 24.2% vs VKA 58.1%; HR:0.31(95%CI 0.14-0.68), p=0.003; Adjusted HR: 0.23(95%CI 0.09-0.57), p=0.001].Conclusions: This observational study suggests triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was accompanied with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.

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