Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus

Abstract

Aims Left ventricular (LV) thrombus is increasingly detected in patients with and without ischaemic heart disease due to the increased availability of cardiac magnetic resonance imaging. Risk factors include anterior ST elevation myocardial infarction, delayed reperfusion therapy, and non-ischaemic cardiomyopathy with severe LV systolic dysfunction. We aimed to report the characteristics and outcomes of patients with LV thrombus treated with either vitamin K antagonist (VKA) or direct oral anticoagulants (DOAC) with a view to describing differences in efficacy, specifically, subsequent thromboembolic events, thrombus resolution, and also side effects of therapy including clinically significant bleeding. Methods and results We conducted a retrospective, observational cohort study of patients diagnosed with LV thrombus between 1 December 2012 and 30 June 2018 and treated with either DOAC or VKA. We recorded patient demographics, past medical history, prescribed medications, and baseline investigations. The primary outcomes were rates of thromboembolism and clinically significant bleeding, with secondary outcomes of thrombus resolution on repeat cardiac imaging, repeat hospitalization, and all-cause mortality. During the study period, 84 patients were diagnosed with and managed for LV thrombus. Of these, 62 received VKA and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran. Most patients 75 (89%) were male with an average age of 62 ± 14 years. Ischaemic heart disease was the cause of LV impairment in 73 (87%) patients. Baseline characteristics were similar between groups at baseline. Most n = 55 (65%) were co-prescribed a single antiplatelet agent and 32 (38%) received dual-antiplatelet therapy. During an average follow-up of 3.0 ± 1.4 years, there were no statistically significant differences between VKA and DOAC in rates of stroke (2% vs. 0%, P = 0.55), other thromboemboli (2% vs. 0%, P = 0.55), or clinically significant bleeding (10% vs. 0%, P = 0.13). The average interval to cardiac imaging follow-up was 233 ± 251 days and was not different between groups (P = 0.83), and there was no difference in the rate of resolution of thrombus (76% vs. 65% P = 0.33). Rehospitalization (50% vs. 45%: P = 0.53) and all-cause mortality (10% vs. 14%; P = 0.61) were also similar. Conclusions Our data suggest that DOACs are likely to be at least as effective and safe as VKA for stroke prevention in patients with LV thrombus and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting. The optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high-risk patients, should be tested in prospective, randomized trials.

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

“…These results are consistent with results seen in some prior retrospective studies, where safety and e cacy of DOAC was comparable to warfarin for SSE prevention. [12,14,24,25] Our results are contrary to those of Robinson et al, who reported that treatment with DOACs was associated with a higher risk of SSE compared to warfarin. [13] It is important to note that in this study, DOAC group had more patients with traditional risk factors of stroke like history of prior SSE, hyperlipidemia, atrial brillation, apical thrombus and pedunculated thrombus which could have contributed to more SSE events.…”

Novel Oral Anticoagulants versus Vitamin K Antagonists for Patients with Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

“…Ten studies reported the occurrence of SSE [5][6][7][8][9][20][21][22][23][24][25] . The NOACs group and VKAs group did not show a significant difference in the risk of SSE (RR:0.96, 95% CI: 0.80-1.16, P = 0.69; I 2 = 0%, figure 3A).…”

“…Eight studies reported the outcome of strokes 6,9,[19][20][21][22]24,25 . NOACs users showed lower risk of stroke compared with VKAs users (RR: 0.68, 95% CI: 0.68-1.00, P < 0.05, Figure 2B).…”

“…Eleven studies investigated the outcome of failure in thrombus resolution [5][6][7][8][9][16][17][18][19]21,22,24,25 , and the resolution rate was similar in two groups (RR: 0.88, 95% CI: 0.72-1.09, P = 0.20, Figure 2C Supplementary figure 3C). Efficacy for thrombus resolution was consistent despite follow-up duration (P interaction = 0.94), sample size (P interaction = 0.26) and anti-platelet medication (P interaction = 0.43) in subgroup analysis ( Table 2).…”

“…Current guidelines recommend vitamin K antagonists (VKAs) for LVT patients based on limited evidence from observational studies [1][2][3][4] . However, off-label use of novel oral anticoagulants (NOACs) for LVT is gaining interest, as they provide more constant anticoagulant effects and do not require continuous monitor of international normalized ratio (INR) 1,[5][6][7][8][9] . Numerous trials and analysis have already proved NOACs acquire similar efficacy in SSE prevention and lower bleeding risk in other clinical scenarios (e.g.…”