Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus

Lattuca, Benoît; Bouziri, Nesrine; Kernéis, Mathieu; Portal, Jean-Jacques; Zhou, Jian; Hauguel-Moreau, Marie; Mameri, Amel; Zeitouni, Michel; Guedeney, Paul; Hammoudi, Nadjib; Isnard, Richard; Pousset, Françoise; Collet, Jean‐Philippe; Vicaut, Éric; Montalescot, Gilles; Silvain, Johanne

doi:10.1016/j.jacc.2020.01.057

Cited by 160 publications

(195 citation statements)

References 21 publications

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“…Study by Lattuca et al suggests treating LV thrombus patients with > 3 months (regardless of type of anticoagulation) is associated with less major adverse cardiovascular events (MACE), which included death, stroke, myocardial infarction, or acute peripheral artery emboli. [35] Based on the ndings of our analysis, although it may appear that the two treatments share a similar clinical and safety pro le, we do not recommend using DOACs for left ventricular thrombus. The results of our study are hypothesis generating for further studies to evaluate the comparative effectiveness of DOACs compared to warfarin.…”

Section: Discussionmentioning

confidence: 83%

“…[7] Not surprisingly, with adequate anticoagulation the occurrence of embolic events can be decreased. [7,35] DOACs are a newer class of anticoagulants -with the rst agent approved by the Food and Drugs Administration (FDA) in 2010. DOACs are indicated for the treatment of conditions such as non-valvular atrial brillation and venous thromboembolism.…”

Section: Discussionmentioning

confidence: 99%

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Warfarin Versus Direct Oral Anticoagulants for Treating Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Dalia

Lahan

Ranka

et al. 2020

Preprint

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Background: Left ventricular thrombus (LVT) is not uncommon and pose a risk of systemic embolism, which can be mitigated by adequate anticoagulation. Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to warfarin for anticoagulation, but their efficacy and safety profile has been debated. We aim to compare the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT.Methodology: We systematically searched PubMed/Medline, Google Scholar, Cochrane library, and LILCAS databases from inception to 14th August 2020 to identify relevant studies comparing warfarin and DOACs for LVT treatment and used the pooled data extracted from retrieved studies to perform a meta-analysis.Results: We report pooled data on 1955 patients from 8 studies, with a mean age of 61 years and 59.7 years in warfarin and DOACs group, respectively. The pooled odds ratio for thrombus resolution was 1.11 (95% CI 0.51–2.39) on comparing warfarin to DOAC, but it did not reach a statistical significance (p = 0.76). The pooled risk ratio (RR) of stroke or systemic embolization and bleeding in patients treated with warfarin vs DOACs was 1.04 (95% CI 0.64–1.68; p = 0.85), and 1.15 (95% CI 0.62–2.13; p = 0.57), respectively; with an overall RR of 1.09 (95% CI 0.70–1.70; p =0.48) for mortality.Conclusions: DOACs appears to be non-inferior or at least as effective as warfarin in the treatment of left ventricular thrombus without any statistical difference in stroke or bleeding complications.

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Section: Discussionmentioning

confidence: 83%

Section: Discussionmentioning

confidence: 99%

Warfarin Versus Direct Oral Anticoagulants for Treating Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Dalia

Lahan

Ranka

et al. 2020

Preprint

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“…There is paucity of literature on the use of DOACs in LVT. In a recent well-conducted single center study with 157 patients, the authors reported a stroke/ embolism rate of 22.2% over a median follow up of 632 days [ 6 ]. In this study, 77 patients were on vitamin K antagonists (most were on fluindione) and 36 were on DOACs.…”

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confidence: 99%

Direct oral anticoagulant use in left ventricular thrombus

et al. 2020

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Left ventricular thrombus (LVT) is associated with a significant risk of ischemic stroke (IS) and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. We studied the natural history of LVT with anticoagulation (AC) with emphasis on comparing warfarin and DOAC use. In this single center study, we identified patients with a confirmed LVT. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, and thrombus resolution) were recorded. LVT was confirmed in a total of 110 patients. Mean age was 59 + 14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients. At 1 year follow up, 11 patients (10%) had a stroke while on any AC (2 had hemorrhagic stroke and 9 had IS). Of those with IS, 7 were on warfarin (71% of those had subtherapeutic INR) and 2 patients on DOACs had IS. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p = 0.33). 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p = 0.85). One-year risk of stroke with LVT is high (10%) even with AC. Most patients IS on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients.

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“…Conversely, patients with persistent LVT were at high risk of clinical complications even when combining with antiplatelet agents. 11 The observation that in this cohort as many as 1/3 of patients did not achieve total LVT regression and that even 14.5% had recurrent or increased size of LVT emphasize the need for more efficient therapeutic strategies to improve and accelerate LVT regression. Yet, any intensification of the antithrombotic treatment may be compromised by more frequent and more severe bleeding complications.…”

Section: Echoc Ardiog R Aphy and Clinic Al Manag Ementmentioning

confidence: 69%

“…This observation underscores that refinement in the treatment strategies for LVT is needed to improve clinical outcomes considering that the clinical prognosis of patients with LVT remains poor, with a very high risk of major cardiovascular events and mortality. 11 In the light of these observations, the recent advances in ultrasound technology and the use of sequential contrast agents may potentially help clinicians in defining the adequate and tailored tion, but it is a time-consuming and expensive test not available in all centers, especially when repeated examinations are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT.…”

mentioning

confidence: 99%

Optimal Use of Echocardiography in Management of Thrombosis After Anterior Myocardial Infarction

et al. 2020

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Despite advancement in therapy and management, left ventricular thrombus (LVT) after anterior myocardial infarction (MI) is sporadically encountered and remains associated with a very high risk of major cardiovascular events and mortality. Cardiac magnetic resonance (CMR) is considered the gold standard technique for LVT detection, but it is a time‐consuming and expensive test not available in all centers, especially when repeated examinations are necessary. Transthoracic echocardiography represents a useful tool to screen for LVT and to identify predictors of high risk of developing LVT. The advances in ultrasound technology and the use of contrast agents may potentially help clinicians to identify LVT and the use of sequential echocardiography for each patient with acute MI complicated by LVT may provide an opportunity to quantify regression and its correlation with outcomes to tailor the management of these patients. Hence, this narrative review focuses on the added value of echocardiographic‐guided LVT management in patients with recent anterior MI to reduce mortality and morbidity excess related to LVT based on current evidence.

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Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus

Cited by 160 publications

References 21 publications

Warfarin Versus Direct Oral Anticoagulants for Treating Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Warfarin Versus Direct Oral Anticoagulants for Treating Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Direct oral anticoagulant use in left ventricular thrombus

Optimal Use of Echocardiography in Management of Thrombosis After Anterior Myocardial Infarction

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