459Direct oral anticoagulants are an effective therapy for left ventricular thrombus formation

Abstract

Background and aim Left ventricular thrombus is a frequent complication of myocardial infarction (MI) and heart failure with severely depressed ejection fraction. Once diagnosed, anticoagulation for up to 6-months is recommended, but clinical experience with direct oral anticoagulation (DOAC) is limited to a few case reports. Our aim is to test DOAC LV thrombus resolution efficacy against warfarin. Methods Single-centre retrospective cohort study of consecutive patients with recently diagnosed LV thrombus, either after acute myocardial infarction or heart failure with reduced ejection fraction, from January 2009 till December 2018. Thrombus diagnosis and subsequent assessments were performed with echocardiography and complemented with cardiac magnetic resonance, when appropriate. Decisions regarding the type, dose and duration of anticoagulation and any concomitant antiplatelet therapy were left to physician's judgement. Results In a population of 66 patients (51 male, mean age 69±12 years), 13 received DOAC therapy, with the remainder receiving vit. K antagonists. One from each group was lost to follow up. The DOAC subgroup had higher prevalence of atrial fibrillation, higher left ventricular end-diastolic volumes and worse wall motion severity score index (WMSI). The duration of anticoagulant therapy, concomitant single or dual antiplatelet therapy and overall follow up were similar between strategies. Thrombus remission was observed in 91.7% (n=11) and 59.6% (n=31) patients within DOAC and warfarin group, respectively. Risk of unsuccessful resolution was reduced by 35% relative to the warfarin group (RR 0.65; 95% CI [0.491–0.862]; p-value 0.035) (figure). figure Conclusion DOAC seems to be an effective alternative to vitamin-K antagonists in patients with LV thrombus.

Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: A Retrospective, Multicenter Study and Meta-Analysis of Existing Data

“…After systematic review, a total of 6 studies (2 fully published papers and 3 published abstracts), in addition to our current study were included (n ¼ 408 for DOACs; n ¼ 1207 for VKA). [30][31][32][33][34] Overall, there was no significant differences between patients treated with DOACs versus VKAs for LVT with respect to odds for unresolved thrombus (OR 0.61, 95% CI 0.26,1.41), embolic events (OR 1.24, 95% CI 0.90,1.69), or bleeding events (OR 1.13, 95% CI 0.74,1.72) ( Figure 2). No significant heterogeneity was noted.…”

Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

“…Seventeen studies reported on LV thrombus resolution. [7][8][9][10][17][18][19][20][21][23][24][25][26][27][28][29][30] Twelve studies reported no significant difference in LV thrombus resolution between DOACs and VKAs. [7][8][9][10]18,23,24,[26][27][28][29][30] Three studies 19,20,25 significantly greater LV thrombus resolution with DOACs over the entire study period, and 2 other studies 17,21 found initial resolution to be faster with DOACs, but no significant differences in resolution when measured over the entire study period.…”

“…[7][8][9][10][17][18][19][20][21][23][24][25][26][27][28][29][30] Twelve studies reported no significant difference in LV thrombus resolution between DOACs and VKAs. [7][8][9][10]18,23,24,[26][27][28][29][30] Three studies 19,20,25 significantly greater LV thrombus resolution with DOACs over the entire study period, and 2 other studies 17,21 found initial resolution to be faster with DOACs, but no significant differences in resolution when measured over the entire study period. Jones et al reported consistently higher LV thrombus resolution with DOACs compared with VKAs at different time points through the 1-year follow-up period (82% vs 64.4%, P = 0.0018) even after adjusting for baseline variables (OR 1.8, 95% CI 1.2-2.9).…”

“…There were no significant differences in LV thrombus resolution between those treated with DOACs vs VKAs (OR 1.29, 95% CI 0.83-1.99; P = 0.26; I 2 = 56%). [7][8][9][10][17][18][19][20][21][23][24][25][26][27][28][29][30] LV thrombus resolution was assessed at different time points in individual studies, ranging from 3 to 36 months, and this limits interpretation of the results. Although we did not examine time to LV thrombus resolution, Jones et al identified a greater degree of LV thrombus resolution with DOACs over VKAs at 1 year (81% vs 63%, P = 0.0018), in addition to faster LV thrombus resolution with DOACs.…”

“…In addition, of the 18 studies included in this paper, 8 were not full-text articles, and limited information was available to ascertain baseline characteristics of participants and critically appraise study quality. [17][18][19][24][25][26][27]30 Although our review includes 2 RCTs, additional data from ongoing larger RCTs will aid in understanding the differences between DOACs and VKAs for this indication. [42][43][44] Also, the length of follow-up and outcome definitions varied considerably across studies (Table 1), which affects the conclusions that can be drawn.…”