Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

Abstract

Left ventricular (LV) thrombus formation complicates 15% of acute myocardial infarctions (MIs), and it is even more common in conditions of impaired LV systolic function. [1][2][3] If left untreated, up to 20% of patients can have significant complications, including stroke and systemic embolism. 3 Current consensus guidelines recommend the use of vitamin K antagonists (VKAs) to treat LV thrombi following acute MIs for 3-6 months. 4,5 Direct oral anticoagulants (DOACs) are a preferred alternative to VKAs, as they have lower bleeding rates, fewer drug interactions, rapid onset of action, and decreased need for monitoring. 6 However, the use of DOACs for this indication remains off-label. Many observational studies have shown comparable safety and efficacy of DOACs to VKAs in the management of LV thrombi. [7][8][9] However, a recent large cohort study identified a higher risk of stroke or systemic embolism with DOACs, calling into question their use in the treatment of LV thrombi. 10 The aim of this systematic review and meta-analysis was to compare the safety and efficacy of DOACs to VKAs in the ABSTRACT Background: There is increasing interest in direct oral anticoagulants (DOACs), given their safety and convenience in atrial fibrillation, compared with vitamin K antagonists (VKAs). However, the use of DOACs in left ventricular (LV) thrombi is considered off-label, with current guidelines recommending VKAs. The aim of this meta-analysis was to compare the safety and efficacy of DOACs to VKAs in the management of LV thrombi. Methods: A systematic search was conducted for studies published between January 1, 2009 and January 31, 2021 in PubMed, Embase, and CENTRAL. Included studies compared DOACs to VKAs for the treatment of LV thrombi and reported on relevant outcomes. Odds ratios (ORs) were pooled with a random-effects model. Results: Sixteen cohort studies and 2 randomized controlled trials were identified, which included 2666 patients (DOAC = 674; VKA = 1992). Compared with VKAs, DOACs were associated with a statistically significant reduction in stroke (OR 0.63, 95% confidence interval [CI] 0.42-0.96; P = 0.03; I 2 = 0%). There were no significant differences in bleeding (OR 0.72, 95% CI 0.50-1.02; P = 0.07; I 2 = 0%), systemic embolism (OR 0.77, 95% CI 0.41-1.44; P = 0.41; I 2 = 0%), stroke or systemic embolism (OR 0.83, 95% CI 0.53-1.33; P = 0.45; I 2 = 33%), mortality (OR 1.01, 95% CI 0.64-1.57; P = 0.98; I 2 = 0%) or LV thrombus resolution (OR 1.29, 95% CI 0.83-1.99; P = 0.26; I 2 = 56%).

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

“…In the present study, the pooled results showed a similar SSE risk of DOACs with VKAs in patients with LVT. This was in line with the findings of prior studies [8,25,26,30,37,38]. Michael F, et al [37] performed a meta-analysis to compare the safety and efficacy of DOACs versus VKAs for LVT and found a comparable effect in SSE between the two treatments (odds ratio (OR) = 0.83, 95% CI: 0.53, 1.33; p = 0.45).…”

“…This was in line with the findings of prior studies [8,25,26,30,37,38]. Michael F, et al [37] performed a meta-analysis to compare the safety and efficacy of DOACs versus VKAs for LVT and found a comparable effect in SSE between the two treatments (odds ratio (OR) = 0.83, 95% CI: 0.53, 1.33; p = 0.45). Similarly, in another metaanalysis of Saleh Y, et al [38], the authors observed no sig-nificant difference between rivaroxaban and VKAs in terms of SSE (OR = 0.73, 95% CI: 0.24, 2.22; p = 0.58).…”

Systematic review of efficacy of direct oral anticoagulants and vitamin K antagonists in left ventricular thrombus

“…The sub‐optimal TTR may affect the resolution rate of LVT on VKAs, as mentioned in studies conducted by Alcalai et al ., Ratnayake et al ., Zhang et al 16,28,34 . One previous study recommended performing LVT imaging using delayed enhancement CMRI and transesophageal echocardiography, with follow‐up time points in the range of 3–12 months 36 . The diagnostic methods and follow‐up duration of the included studies were not entirely consistent, which may have influenced our findings.…”

“…Almost 50% of the studies included in the study by Michael et al . involved abstracts without complete experimental data, 36 which may influence the generalizability of their results. Moreover, more studies comparing DOACs and VKAs in the treatment of LVT have been published recently 15,22,24,26,27,30–34 .…”

Therapeutic efficacy of direct oral anticoagulants and vitamin K antagonists for left ventricular thrombus: Systematic review and meta-analysis

“…Recently, several meta-analysis articles have been published comparing VKAs and DOACs in treatment of LVT [17][18][19][20][21][22][23][24]. However, these meta-analyses included only direct comparative studies between VKAs and DOACs, and did not include single-arm studies.…”