Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta‐analysis

Abstract

Warfarin is the most studied initial OAC agent for treating LAT in nonrheumatic AF and/or AFL with a resolution rate of nearly 80%. Further studies in DOACs are warranted.

Non‐vitamin K oral anticoagulants versus warfarin for left atrial appendage thrombus resolution in nonvalvular atrial fibrillation or flutter

“…A recent systematic review published by our group yielded 17 vitamin K antagonist (VKA) studies and only two NOAC studies. 8 Warfarin studies with low risk of bias demonstrated an estimated 79.3% LA thrombus resolution rate after 3 weeks or more. Equivalency between warfarin and NOACs in this clinical scenario should not be assumed given few NOAC studies.…”

Risk assessment and management of atrial fibrillation patients with left atrial thrombus

“…In a recent issue of Pacing and Clinical Electrophysiology , Wang et al . report a systematic review and meta‐analysis on LAT resolution with OACs.…”

Oral anticoagulants for left atrial thrombus resolution in nonvalvular atrial fibrillation or flutter: Building the pyramid of evidence for off‐label drug use

“…We feel it is important to emphasize the utility of our study in the larger context of OAC agent selection for this clinical scenario. Warfarin, with a LA thrombus resolution rate of approximately 80%, is currently the only OAC agent approved by the United States Food and Drug Administration (FDA) for “treatment of the thromboembolic complications associated with atrial fibrillation.” NOAC selection for treatment of LA thrombus is off‐label and, in OAC naïve patients, chosen over an OAC agent that is both FDA approved and has fairly robust efficacy and effectiveness data. Off‐label drug use, while often reasonable, is not without risk and may bear legal consequences Neither the 2014 guideline for the management of patients with AF nor the 2019 focused update issued by the American Heart Association, American College of Cardiology, and Heart Rhythm Society specify the type of OAC agent that is preferred for treatment of LA thrombus when detected by TEE prior to consideration for cardioversion…”

“…Retrospective cohort studies are important to build the “pyramid of evidence,” given few NOAC studies . It is our anticipation that multicenter randomized controlled trials and prospective cohort studies will ultimately address whether NOACs are reasonable, or perhaps even preferable, alternatives to warfarin for treatment of LA thrombus in nonvalvular AF or flutter.…”

“…5,6 Retrospective cohort studies are important to build the "pyramid of evidence," 7 given few NOAC studies. 1,2 It is our anticipation that multicenter randomized controlled trials and prospective cohort studies will ultimately address whether NOACs are reasonable, or perhaps even preferable, alternatives to warfarin for treatment of LA thrombus in nonvalvular AF or flutter. LA thrombus resolution rates from smaller studies provide important preliminary data for power calculations to determine target sample sizes for such definitive studies.…”