Efficacy and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombus: A Systematic Review and Meta-analysis

Abstract

Background: Left ventricular thrombus (LVT) may develop in systolic heart failure or after acute myocardial infarction. The current recommendations support the use of vitamin K antagonists (VKAs) for the treatment of LVT. Limited data exist regarding the use of direct oral anticoagulants (DOACs) in patients with LVT. This meta-analysis aims to investigate the efficacy and safety of DOACs versus VKAs for LVT. Methods: We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases through November 2020 for all studies that evaluated the efficacy and safety of DOACs versus VKAs in patients with LVT. The primary outcomes were LVT resolution, overall thromboembolic events, and thromboembolic stroke. The secondary outcomes were major bleeding and all-cause mortality. Pooled risk ratio (RR) and 95% confidence intervals (CIs) were obtained by the Mantel–Haenszel method within a random-effects model. Heterogeneity was assessed by I 2 statistic. Results: A total of 11 studies including 2153 patients with LVT on anticoagulation (570 on DOACs vs. 1583 on VKAs) were included. LVT resolution was significantly higher in DOACs compared with VKAs [RR: 1.18 (95% CI: 1.04–1.35); P = 0.01, I 2 = 25%]. However, no significant difference existed between DOACs and VKAs regarding overall thromboembolic events [RR: 1.10 (95% CI: 0.75–1.62); P = 0.61, I 2 = 0%] and thromboembolic stroke [RR: 0.63 (95% CI: 0.39–1.02); P = 0.06, I 2 = 0%]. Major bleeding [RR: 1.00 (95% CI: 0.66–1.51); P = 0.99, I 2 = 4%] and all-cause mortality [RR: 0.84 (95% CI: 0.50–1.43); P = 0.53, I 2 = 0%] were similar between the 2 groups. Conclusions: DOACs seem to be more efficacious in achieving LVT resolution compared with VKAs. However, there was no significant difference between the 2 groups in thromboembolic events, major bleeding, and all-cause mortality. Randomized controlled trials are needed to confirm our findings.

Different Oral Antithrombotic Therapy for the Treatment of Ventricular Thrombus: An Observational Study from 2010 to 2019

“…Several meta-analyses reported results similar to ours. Burmeister et al (2021 concluded) that patients with NOACs showed a higher rate of thrombus regression (risk ratio = 1.18, 95% confidence interval 1.04–1.35, p = 0.01) while there was no significant difference between the NOACs and VKA groups in stroke, thromboembolism, or any bleeding event [ 24 ]. Two reviews, Saleiro et al [ 18 ] and Camilli et al [ 39 ], comparing NOACs and VKAs in patients with left VT have been published; while the former paper suggested that NOACs were as effective as VKAs for VT with a similar risk of thromboembolism/stroke and bleeding, the latter paper concluded that NOACs were comparable to VKA in terms of thrombus resolution, providing lower bleeding rates and an increase in thromboembolism events in the NOACs group.…”

“…2017 European guidelines also recommended that STEMI patients with left VT should maintain anticoagulation therapy for up to 6 months under the guidance of repeated imaging ( Class II a, level C evidence ) [ 11 ]. Up to date, quite a few studies reported that NOACs had comparable safety and efficacy outcomes in the treatment of VT [ 12 – 24 ]. Michael et al (2021) conducted a meta-analysis to compare NOACs to VKAs for the treatment of left ventricular thrombus, including a total of 18 studies with 2666 patients, and their result showed that NOACs had less 37% risk of stroke than VKAs, while no significances were observed in thrombus resolution, systemic embolism, bleeding, or all-cause death events.…”

A Meta-Analysis Comparing Different Oral Anticoagulation for the Treatment of Ventricular Thrombus

“…No stroke or embolism events were observed, and only one patient experienced nonfatal bleeding. Numerous studies claimed that NOACs were comparable with or even outweighed VKAs [28,[33][34][35][36][37]39,40,[45][46][47], and obviously the most popular or dominant usage of NOACs was rivaroxaban in all studies. It was known that NOACs could be divided into two types targeting various action mechanismanti-Xa inhibitor (rivaroxaban, apixaban and edoxaban or anti-IIa inhibitors (dabigatran).…”

Massive Left Ventricular Thrombus Causing Bilateral Posterior Cerebral Artery Stroke: A Case Report and Review of Literature

“…LVTs have been found to persist even in the setting of percutaneous coronary intervention in the post-MI setting [15]. Current guidelines recommend the use of DOACs, as evidence is largely supportive of efficacy and resolution of thrombosis [16][17][18][19]. Vitamin K antagonists have traditionally been used, but due to the difficulties of monitoring the INR, it can be difficult in the setting of other drug and food interactions [20].…”