Left ventricular thrombi after short-term high-dose anticoagulants in acute myocardial infarction

Abstract

To examine the effect of short-term, high-dose anticoagulation on the subsequent occurrence of left ventricular (LV) thrombi after a first anterior wall acute myocardial infarction (AMI), 21 patients received placebo and 21 high-dose anticoagulants during the first 10 days of the acute infarction. They were studied with cross-sectional echocardiography 10 days and 1.3 and 6 months post infarction. At 1 month, 6 of 7 thrombi present in the placebo group at 10 days were still visible. No thrombi were detected at 10 days in the anticoagulation group, but 6 patients had developed a LV thrombus at 1 month. These 12 patients with LV thrombi were subsequently treated with oral warfarin for 2 months, after which all thrombi had disappeared. Warfarin was then discontinued, and a thrombus had recurred in 5 patients after 6 months. Apical akinesis at 10 days was a predictor for thrombus with a sensitivity and specificity of 100% and 72.2%, respectively. Three of the 13 patients with LV thrombi suffered stroke in contrast to none without thrombi (P = 0.025). We conclude that after discontinuation of short-term high-dose anticoagulation therapy in anterior AMI, LV thrombi may develop rapidly and lead to embolic complications, particularly in patients with persisting apical akinesis.

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition. Response to Gosai & Muthusamy

“…Regression in size of the thrombus was seen in those treated with anticoagulation. Low levels of symptomatic systemic embolization were seen in this and other studies that demonstrated similar incidence (Visser et al, 1985;Johannessen et al, 1987;Keren et al, 1990). In a review, Cregler (1992) advocated 3 months of warfarin therapy for those with large anterior myocardial infarction or post-infarct heart failure.…”

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition

“…Regression in size of the thrombus was seen in those treated with anticoagulation. Low levels of symptomatic systemic embolization were seen in this and other studies that demonstrated similar incidence (Visser et al, 1985;Johannessen et al, 1987;Keren et al, 1990). In a review, Cregler (1992) advocated 3 months of warfarin therapy for those with large anterior myocardial infarction or post-infarct heart failure.…”

ACC/AHA 2004 guideline update for coronary artery bypass graft surgery

“…A recent, preoperative cerebrovascular accident presents another situation in which delaying the operation may reduce the perioperative neurological risk. Evidence of a hemorrhagic component to the cerebrovascular accident, based on the results of a computed tomography scan, identifies those patients at particular risk for extension of the neurological damage due to heparinization and CPB (189). It is generally believed that a delay of 4 weeks or more is prudent if coronary anatomy and symptoms permit.…”