Comment on Guidelines on oral anticoagulation with warfarin – 4th edition. Response to Gosai & Muthusamy

Abstract

As far back as 1983, immediate anticoagulation was advocated for all patients with left ventricular thrombus, and consideration of long-term anticoagulation in this group (Nixon, 1983). Küpper et al (1989) demonstrated an incidence of over 30% in 92 patients with acute anterior myocardial infarction, and these patients had a poorer outcome. Regression in size of the thrombus was seen in those treated with anticoagulation. Low levels of symptomatic systemic embolization were seen in this and other studies that demonstrated similar incidence (Visser et al, 1985;Johannessen et al, 1987;Keren et al, 1990). In a review, Cregler (1992) advocated 3 months of warfarin therapy for those with large anterior myocardial infarction or post-infarct heart failure. In all of the available literature, thrombus development was identified within 5 d of the index infarction and usually within 48 h. With current management of myocardial infarction, warfarinization of patients is no longer recommended.We were unable to identify any recent evidence related to the management of left ventricular thrombus. Currently available evidence may no longer be applicable following the introduction and widespread use of the thienopyridine antiplatelet agents and the move away from thrombolysis toward primary coronary angioplasty for myocardial infarction. There is little available evidence in relation to the management of intracardiac thrombus in non-infarct related cardiomyopathies.