Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association

Abstract

Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.

A genetic risk score improves risk stratification for anticoagulation-related intracerebral hemorrhage

“…35 Anticoagulant users are at increased ICH risk, and the additional knowledge of individual genetic ICH risk could influence clinical decision making in situations with limited evidence or equivocality of clinical parameters. For potential cardioembolic sources of ischemic stroke such as left ventricular aneurysm, 8 ventricular thrombus, 36 or low ejection fraction, 37 anticoagulation indications are controversial, but also for well-established indications such as deep venous thrombosis, pulmonary embolism, and cerebral sinus thrombosis, duration of anticoagulation is uncertain and provoked versus unprovoked status can be ambiguous. [5][6][7][8][9] Randomized controlled trials validating bleeding risk scores are missing, but the clinical utility is demonstrated by the mentioning of HAS-BLED in American and European guidelines.…”

Improving the management of left ventricular thrombus in a tertiary cardiology centre: a quality improvement project

“…5 The off-label use of direct oral anticoagulants (DOAC) has become an attractive alternative in this setting due to their lack of need for monitoring and dose adjustments. 6 DOACs have become contemporary treatments for other cardiovascular conditions including non-valvular atrial fibrillation, in which their efficacy is similar to VKA, despite lower rates of bleeding. 2 However, it is currently unclear whether DOACs have similar efficacy as VKA in terms of reducing the risk of systemic embolism including stroke and thrombus resolution in the setting of LV thrombus.…”

Comparative Pharmacology of Direct Oral Anticoagulants and Vitamin K Antagonist

“…1,2,5,7 The current approaches to managing incidence of LVT include use of Vitamin K antagonists (VKA) and/or Direct oral anticoagulants (DOAC) until resolution of the thrombus (~3 to 6 months). 1,5,[7][8][9] Although recent clinical approaches show preferential use of DOAC over VKA, due to better patient compliance and drug safety issues (reduced bleeding and limited adverse drug interactions). [10][11][12][13] Currently the following five DOAC are available to be used for the prevention of thrombosis, i.e., dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban.…”