Direct Oral Anticoagulants Versus Warfarin in the Treatment of Left Ventricular Thrombus

Abstract

Background Use of direct oral anticoagulants (DOACs) for the treatment of left ventricular (LV) thrombus has gained considerable interest. Objective We aimed to evaluate if DOACs are effective in the treatment of LV thrombus compared with warfarin. Methods We evaluated the medical records of patients diagnosed with a new LV thrombus at a tertiary medical center. The primary outcome was the composite of thrombus persistence, stroke, or systemic embolism. We adjusted for potential confounders using multiple logistic regression. The safety outcome was the composite of hemorrhagic stroke or bleeding requiring blood transfusion. Results A total of 129 patients were treated with warfarin and 22, with a DOAC. In unadjusted analysis, 54.3% of patients treated with warfarin met criteria for the efficacy outcome as compared with 40.9% of patients treated with a DOAC ( P = 0.25). In adjusted analysis, no difference between groups was observed (odds ratio = 0.39; 95% CI = 0.14-1.06; P = 0.07 for DOAC vs warfarin). In all, 3.9% of patients treated with warfarin met safety criteria as compared with 4.5% of patients treated with a DOAC. A total of 8 patients in the warfarin group had a stroke or systemic embolism as compared with 0 patients in the DOAC group ( P = 0.37). Conclusion and Relevance Our data suggest that DOACs may be reasonable alternatives for treatment of LV thrombus. When added to the totality of available studies, this study demonstrates that the effectiveness of DOACs in LV thrombus remains uncertain. Randomized clinical trials are needed.

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

“…Nine studies reported bleeding events 6,9,16,19-22,24,25 , the risk of any bleedings was similar for NOACs and VKAs users (RR: 0.94, 95% CI: 0.67-1.31, P = 0.70; I 2 = 24%, Figure 2D ), without significant bias for publication as shown in the funnel plot ( Supplementary figure 1D) . Meta-regression showed age did not differentiate the safety of NOACs or VKAs (RR: 1.03, 95% CI: 0.81-1.31, P = 0.764, Supplementary figure 3D ).…”

“…In six studies reporting clinically relevant bleedings 6,9,16,22,24,25 , NOACs users showed more favorable outcomes (RR: 0.35, 95% CI: 0.13-0.92, P = 0.03; I 2 = 0, Figure 2E ), and no significant publication bias was detected by the funnel plot ( Supplementary figure 1E ). Age did not affect the difference in clinically relevant bleeding risk between NOACs and VKAs (RR: 0.83, 95% CI:0.41-1.69, P = 0.516, Supplementary figure 3E ).…”

“…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.…”

“…Subgroup analysis for follow-up duration (P interaction = 0.07), sample size (P interaction = 0.09), concomitant antiplatelet medication (P interaction = 0.48) and primary causes of LVT (P interaction = 0.09) showed a consistently similar effect of NOACs and VKAs ( Table 2 ). Eight studies reported the outcome of strokes 6,9,19-22,24,25 . 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 5-9,16-19,21,22,24,25 , 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 ).…”