P6426The use of direct oral anti-coagulations (DOACs) compared to vitamin k antagonist in patients with left ventricular thrombus after acute myocardial infarction

Abstract

Aim Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI. Methods and results This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome. Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia). Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388). Conclusion This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data. Acknowledgement/Funding None

Direct Oral Anticoagulants versus Vitamin K Antagonists for Patients with Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

“…Finally, thirteen articles were included in the synthetic analysis, two of which were prospective studies [5][6][7][8][9][16][17][18][19][20][21][22][23].…”

Novel Oral Anticoagulants versus Vitamin K Antagonists for Patients with Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

“…In six studies reporting clinically relevant bleedings 6,9,16,22,24,25 , NOACs users showed more favorable outcomes (RR: 0.35, 95% CI: 0.13-0.92, P = 0.03; I 2 = 0, Figure 2E ), and no significant publication bias was detected by the funnel plot ( Supplementary figure 1E ). Age did not affect the difference in clinically relevant bleeding risk between NOACs and VKAs (RR: 0.83, 95% CI:0.41-1.69, P = 0.516, Supplementary figure 3E ).…”

“…Eleven studies investigated the outcome of failure in thrombus resolution 5-9,16-19,21,22,24,25 , and the resolution rate was similar in two groups (RR: 0.88, 95% CI: 0.72-1.09, P = 0.20, Figure 2C ), with an low statistical heterogeneity (I 2 = 26%, P = 0.20) and no significant publication bias based on the funnel plot ( Supplementary figure 1C ) and statistical tests (Begg’s test, P = 0.484; Egger’s test, P = 0.191). Age did not show substantial impacts on thrombus resolution according to meta-regression (RR: 1.08, 95% CI: 0.95-1.22, P = 0.215, Supplementary figure 3C ).…”

“…Eleven studies investigated the outcome of failure in thrombus resolution [5][6][7][8][9][16][17][18][19]21,22,24,25 , and the resolution rate was similar in two groups (RR: 0.88, 95% CI: 0.72-1.09, P = 0.20, Figure 2C Supplementary figure 3C). Efficacy for thrombus resolution was consistent despite follow-up duration (P interaction = 0.94), sample size (P interaction = 0.26) and anti-platelet medication (P interaction = 0.43) in subgroup analysis ( Table 2).…”

“…Nine studies reported bleeding events 6,9,16,[19][20][21][22]24,25 , the risk of any bleedings was similar for NOACs and VKAs users (RR: 0.94, 95% CI: 0.67-1.31, P = 0.70; I 2 = 24%, Figure 2D), without significant bias for publication as shown in the funnel plot (Supplementary figure 1D). Meta-regression showed age did not differentiate the safety of NOACs or VKAs (RR: 1.03, 95% CI: 0.81-1.31, P = 0.764, Supplementary figure 3D).…”