Evaluation of Direct Oral Anticoagulants Versus Warfarin for Intracardiac Thromboses

Abstract

Intracardiac thrombus (ICT) formation is a common complication of several cardiovascular diseases. Warfarin is recommended for treatment of ICT by guidelines based on observational studies occurring before the advent of nonvitamin K antagonist direct oral anticoagulants (DOACs). We aim to evaluate the current prescribing patterns at our institution and to compare the efficacy and safety profiles of warfarin versus DOACs for ICT. This is a retrospective review of adult patients treated with oral anticoagulation for ICT between May 2013 and December 2019. Our primary end point was complete thrombus resolution. Secondary outcomes included time to resolution of thrombus, treatment failure, and duration of therapy. Safety end points included stroke and systemic embolization (SSE) and bleeding events. A total of 123 patients were included (DOAC n = 61; warfarin n = 62). At baseline, more patients in the DOAC group had anemia [6 (10%) vs. 0 (0%), P = 0.013] and alcohol use disorder [6 (10%) vs. 0 (0%), P = 0.013]. Complete thrombus resolution occurred in 50 (82%) and 46 (74%) patients in the DOAC and warfarin groups, respectively (P = 0.298). There was a shorter time to thrombus resolution in the DOAC group versus the warfarin group {63 days [interquartile range (IQR) 40-138] vs. 123 days , P = 0.003}. There were no differences found in SSE or bleeding between the groups [DOAC 11 (19%) vs. warfarin 17 (28%), P = 0.213]. For patients with an ICT, treatment with a DOAC for at least 3 months may be a comparable alternative to warfarin in safety and efficacy.

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

“…In aspects of our key findings, patients who received NOACs had a greater resolution more than 1 time than those with VKAs or APT, which was consistent with several articles [ 12 , 26 ]. Researchers have explored the effectiveness of NOACs in the treatment of VT. Sedhom et al collected 85 cases of direct oral anticoagulants for treatment of left VT. 74 patients (87%) were prescribed an NOAC and 93.2% of them had a complete resolution (69/74) [ 37 ].…”

“…In a retrospective study including 101 patients with left VT, 41 (40.6%) received NOACs and 60 (59.4%) received VKA at 1-year follow-up, and the NOACs group had a faster and earlier thrombolysis rate than VKA (82% versus 64.4%), a similar rate of thromboembolism (5% versus 2.4%, p = 0.388), and a lower incidence of bleeding events (0% versus 6.7%, p = 0.03) [ 26 ]. Another study also found that the time of thrombus resolution in the NOACs group was faster than that in the VKAs group (63 days [IQR 40, 138] versus 123 days [IQR 86, 244], p = 0.003) [ 12 ]. Bass et al 2021 retrospectively included 949 patients diagnosed with left VT; 180 (19%) received NOACs and 769 (81%) received warfarin, and no differences in new embolism or bleeding events were observed (NOACs versus warfarin: 7.8% versus 11.7%, p = 0.13; 10.9% versus 7.8%, p = 0.40) [ 38 ].…”

“…Otherwise, while most studies mainly compared the efficacy and safety between NOACs and VKAs [ 12 – 23 ] ( Table S6 ), our study firstly offered a new idea towards exploring APT in VT treatment. Our study showed that the rates of bleeding, embolism, and all-cause death were similar among the NOACs, VKAs, and APT groups within a 12 months' follow-up.…”

“…Second, the short duration or small dosage of anticoagulation could produce low efficacy of anticoagulation, and some patients who were already on oral anticoagulation might have a poor adherence such as bad monitoring of INR or irregular treatment. Otherwise, while most studies mainly compared the efficacy and safety between NOACs and VKAs [12][13][14][15][16][17][18][19][20][21][22][23] (Table S6), our study firstly offered a new idea towards exploring APT in VT treatment. Our study showed that the rates of bleeding, embolism, and all-cause death were similar among the NOACs, VKAs, and APT groups within a 12 months' follow-up.…”

“…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][13][14][15][16][17][18][19][20][21][22][23][24]. Michael et al (2021) conducted a metaanalysis 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.…”