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

Abstract

Aim: To compare the safety and efficacy of direct oral anticoagulants (DOAC) relative to vitamin K antagonists (VKA) for the treatment of left ventricular thrombus (LVT). Methods: This retrospective study enrolled patients diagnosed with LVT from 2014-2017. Patient characteristics and outcomes within 12 months of LVT diagnosis were recorded and analyzed. A meta-analysis was also performed by pooling our results with existing data in literature. Results: 14 DOAC and 59 VKA patients were included. Baseline demographic and clinical characteristics were similar except for age. Although more strokes within 12 months occurred in VKA (15%) than in DOAC (0%) patients, this was not statistically significant (p = 0.189). There were no significant differences in outcomes between patients on DOAC and VKA for acute coronary syndrome (ACS) (7%, vs 3.4%, p = .477), LVT resolution (86% vs 76%, p = .499) or bleeding (14% vs 14%, p = 1) within 12 months. The meta-analysis included 6 studies (n = 408 for DOACs; n = 1207 for VKA). There were no significant differences between DOACs versus VKAs 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), embolic events and death (OR 1.10, 95% CI 0.84,1.45) or bleeding events (OR 1.13, 95% CI 0.74,1.72). Conclusions: Our study and meta-analysis suggest similar efficacy and safety of DOACs in the treatment of LVT compared to VKA. These findings underscore the need for a randomized controlled trial.

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

“…Taken together, NOACs did not increase the risk of SSE for LVT patients, and effectively reduced the risk of stroke as compared with VKAs, possibly due to its more constant anticoagulation effects. Moreover, the current study showed thrombus resolution rate was similar for NOACs and VKAs users, which was consistent with previous reports 21,27 . Interestingly, MI patients receiving NOACs showed significantly higher rates of thrombus resolution compared to those using VKAs.…”

“…Growing numbers of cases and clinical studies also suggest a satisfactory outcome for LVT patients using NOACs 6-9 . Although the current analysis suggested no difference between NOACs and VKAs for their efficacy in SSE prevention, as reported by other recently published meta-analysis 21,27 , it was definitely of great clinical importance as it showed a 32% risk reduction for strokes alone in NOACs users. Subgroup analysis also showed a highly homogenous reduction in the risk of stroke across various confounders.…”

“…Subgroup analysis also showed a highly homogenous reduction in the risk of stroke across various confounders. A recently published pooled-analysis by Zhou et al shows no difference in stroke (odds ratio: 0.79, 95% CI: 0.50-1.23) for NOACs and VKAs users 27 , but the current studies included three newly published research in this year 21,24,25 , which enlarged the sample size and provided greater power to test the difference between two medications. Although the interpretation was challenging, one of the main reasons could be the fluctuation of the INR.…”

“…Eleven studies investigated the outcome of failure in thrombus resolution 5-9,16-19,21,22,24,25 , and the resolution rate was similar in two groups (RR: 0.88, 95% CI: 0.72-1.09, P = 0.20, Figure 2C ), with an low statistical heterogeneity (I 2 = 26%, P = 0.20) and no significant publication bias based on the funnel plot ( Supplementary figure 1C ) and statistical tests (Begg’s test, P = 0.484; Egger’s test, P = 0.191). Age did not show substantial impacts on thrombus resolution according to meta-regression (RR: 1.08, 95% CI: 0.95-1.22, P = 0.215, Supplementary figure 3C ).…”

“…However, up to 15% of their patients switched anticoagulants during the follow-up, making it hard to estimate the true risk difference between NOACs and warfarin. In two recent studies on the same topic, impacts from this issue are less discussed 21,27 . In the current analysis taking an intention-to-treat approach, the inclusion and exclusion of this study did not bring much variation to the pooled effect and heterogeneity, which affirmed the neutral results in pooled analysis.…”