Warfarin Versus Direct Oral Anticoagulants for Treating Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Abstract

Background: Left ventricular thrombus (LVT) is not uncommon and pose a risk of systemic embolism, which can be mitigated by adequate anticoagulation. Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to warfarin for anticoagulation, but their efficacy and safety profile has been debated. We aim to compare the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT.Methodology: We systematically searched PubMed/Medline, Google Scholar, Cochrane library, and LILCAS databases from inception to 14th August 2020 to identify relevant studies comparing warfarin and DOACs for LVT treatment and used the pooled data extracted from retrieved studies to perform a meta-analysis.Results: We report pooled data on 1955 patients from 8 studies, with a mean age of 61 years and 59.7 years in warfarin and DOACs group, respectively. The pooled odds ratio for thrombus resolution was 1.11 (95% CI 0.51–2.39) on comparing warfarin to DOAC, but it did not reach a statistical significance (p = 0.76). The pooled risk ratio (RR) of stroke or systemic embolization and bleeding in patients treated with warfarin vs DOACs was 1.04 (95% CI 0.64–1.68; p = 0.85), and 1.15 (95% CI 0.62–2.13; p = 0.57), respectively; with an overall RR of 1.09 (95% CI 0.70–1.70; p =0.48) for mortality.Conclusions: DOACs appears to be non-inferior or at least as effective as warfarin in the treatment of left ventricular thrombus without any statistical difference in stroke or bleeding complications.

Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

“…7,9,10,18,24,30 In a meta-analysis by Dalia et al, mortality was found to be 9% higher in patients receiving warfarin compared to those treated with DOACs (risk ratio 1.09, 95% CI 0.70-1.70), but the difference was not statistically significant. 36 This finding is in keeping with our results, which showed no significant mortality benefit with use of one anticoagulant over the other.…”

“…Previous meta-analyses have not examined stroke as an individual outcome, but rather a composite SSE, making this the first review to demonstrate this statistically significant difference. 7,[34][35][36] However, this finding must be contextualized by the limitations of the primary studies, including the inherent bias of cohort studies and the lack of an adjusted analysis. Further studies-ideally in the form of adequately powered RCTsare required to substantiate this finding.…”

“…Although previous reviews have included data from case reports and observational studies, ours is the first to include data from 2 RCTs. [34][35][36]41 Additionally, previously published meta-analyses have examined fewer outcomes and focused on composite SSE. 7,[34][35][36] In contrast, our meta-analysis examined 6 different safety and efficacy outcomes, and assessed stroke and SE as individual outcomes in addition to the composite SSE that previous reviews have examined.…”

“…[34][35][36]41 Additionally, previously published meta-analyses have examined fewer outcomes and focused on composite SSE. 7,[34][35][36] In contrast, our meta-analysis examined 6 different safety and efficacy outcomes, and assessed stroke and SE as individual outcomes in addition to the composite SSE that previous reviews have examined. By doing so, we are the first review to identify a statistically significant reduction in stroke with DOAC use.…”

An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus

“…One nonfatal bleeding event and one stroke event were reported while on a DOAC. Secondly, a meta-analysis by Dalia et al, 21 which pooled data on 1955 patients from 8 studies, was executed in late 2020. This meta-analysis formulated the odds ratio for thrombus resolution and stroke/systemic embolization and bleeding in patients treated with warfarin vs DOACs, reporting that DOACs appear to be noninferior to, or at least as effective as, warfarin in efficacy without any statistical difference in either stroke or bleeding complications.…”