Direct Oral Anticoagulants versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombosis: A Meta-Analysis

Abstract

Background: Vitamin K antagonists (VKAs) have been recommended as first-line anticoagulants for patients with left ventricular thrombosis (LVT). Direct oral anticoagulants (DOACs) are used as an alternative to the standard of care in anticoagulation. The aim of this meta-analysis was to compare the efficacy and safety of VKAs and DOACs in the treatment of patients with LVT. Materials and Methods: Studies were identified by searching the PubMed, Web of Science, and Embase. The main outcomes included stroke or systemic embolism (SSE), thrombus resolution, and bleeding events. The pooled risk ratio (RR) with 95% confidence intervals (CIs) was estimated with fixed effect or random effect models. Results: Seventeen studies were included. Pooled estimate showed that DOACs had comparable efficacy in prevention of SSE (RR = 0.96, 95% CI: 0.80, 1.16; p = 0.677) and thrombus resolution as compared with VKAs (RR = 1.07, 95% CI: 0.97, 1.18; p = 0.193). DOACs significantly decreased the risk of stroke in patients with LVT (RR = 0.68, 95% CI: 0.47, 1.00; p = 0.048). However, this effect was not observed in the sensitive analysis by high-quality studies (RR = 0.69, 95% CI: 0.47, 1.02; p = 0.06). In terms of safety outcomes, DOACs had similar risk of bleeding events (RR = 1.12, 95% CI: 0.80, 1.57; p = 0.386) and clinically relevant bleeding events (RR = 0.49, 95% CI: 0.23, 1.03; p = 0.060). Meta-regression analysis demonstrated that none of the variables (study design, concomitant antiplatelet medication, duration of follow-up, primary cause of LVT, sample size, types of DOACs) had an impact on the risk of SSE, thrombus resolution and bleeding events. Subgroup analysis based on the use of antiplatelet and treatment switching revealed that there were no significant differences among patients with different treatment regimens. Conclusions: Based on the present evidence, both DOACs and VKA offered similar effective and safe outcomes in patients with LVT.

Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta‐analysis

“…Based on the pooled analysis from 19 studies, we found that the observed stroke rates were significantly lower in the DOAC group, with a similar trend in composite events of stroke and systemic embolism between the DOAC and VKA arms. Our findings corroborated with the results from recently conducted similar studies comparing DOAC to VKA for the treatment of LVT 46,47,50 . DOACs are attractive in clinical practice because their use does not require monitoring of PT/INR levels as it is necessary with VKA.…”

“…Our meta‐analysis is the most robust and up‐to‐date study, including all relevant studies. Given the robustness and largest size including 33 studies, our analysis showed significant differences between VKA and DOACs, which was not observed with prior small‐scale meta‐analyses by Huang et al, Condello et al, Chen et al, Kido et al, Li et al, Camilli et al, and scientific documents 3,46–51 . Based on our findings, it is advisable to use the DOAC over VKA to manage LVT, given the better efficacy (thrombus resolution) and safety (lower mortality, bleeding, and stroke rates) profile of DOACs.…”

“…Our findings corroborated with the results from recently conducted similar studies comparing DOAC to VKA for the treatment of LVT. 46,47,50 Our study also carries certain limitations. Firstly, this is a secondary analysis of published data, so it comes with inherent bias and limitations from the primary studies and methodology-associated limitations due to study design.…”

Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus

“…It also highlighted that in post-acute MI patients, the treatment with DOACs might be superior to VKA for the treatment of LV thrombus. The meta-analysis of Li et al confirmed previous results, and in addition, it showed that concomitant antiplatelet medication did not influence the risk of stroke or systemic embolism, thrombus resolution, and bleeding events [ 26 ].…”

“…In other patients, the size of the thrombus remained unchanged, and it was necessary to change the VKA to a DOAC or vice versa. However, it was shown that treatment switching does not change either the embolic or hemorrhagic risk, or the thrombus resolution rate [ 26 ]. Although the vast majority of available data are concordant regarding the higher efficiency and safety of DOACs compared to VKA in patients with post-acute MI LV thrombus, there are case reports of thrombi that are difficult to resolve, do not reduce their size, or even form under anticoagulation.…”