Left ventricular(LV) thrombus results from Virchow's triad with factors such as reduced wall motion, reduced ejection fraction, and myocardial injury contributing to clot formation. While the prevalence is relatively low in the general population with an incidence of 7/10,000 patients, it can complicate up to 39% of anterior MIs. Serious adverse complications can result from LV thrombus including systemic thromboembolism and stroke. To reduce this risk, anticoagulation is the mainstay of treatment. Historically, LV thrombus was treated with vitamin K antagonists. The American and European guidelines recommend oral anticoagulant therapy with warfarin with varying durations from 3-6 months. However, there are no prospective trials comparing warfarin and direct oral anticoagulants(DOACs) as anticoagulation in the treatment of LV thrombus. Current research includes one meta-analysis of only 8 retrospective studies demonstrating non-inferiority of DOACs compared to warfarin. We present further evidence to suggest the noninferiority of DOACs vs warfarin in the treatment of LV thrombus. METHODS:We reviewed all cases of LV thrombus at two facilities in Iowa, United States. Echocardiogram reports were electronically searched for the inclusion terms "ventricular thrombus," "LV thrombus," and "apical thrombus." Each report was then individually reviewed for accuracy and ejection fraction. Individual patient charts were reviewed for selected anticoagulation at the time of diagnosis, for follow-up echocardiograms, and for adverse events including thromboembolism, gastrointestinal bleed, and death. As this was a retrospective nonrandomized chart analysis, the decision to prescribe VKA vs DOAC was largely based on physician preference. Follow-up echocardiogram reports were reviewed for resolution and ejection fraction. Resolution was defined as complete absence of LV thrombus by the next echocardiogram as interpreted by the echocardiographer.RESULTS: Seventy-six patients were included in the study. Fifty-six received warfarin and twenty-three received a DOAC. Resolution was seen in 68% of patients treated with warfarin and in 65% of patients treated with a DOAC. The average ejection fraction at the time of diagnosis and at the time of resolution are listed respectively: warfarin resolved 38% and 40%, warfarin unresolved 29% and 34%, DOAC resolved 35% and 36%, DOAC unresolved 36% and 38%. The average time to follow-up was 147 days (range 9 -681). Complications of gastrointestinal bleed and stroke did not reach statistical significance.CONCLUSIONS: This retrospective study again suggests DOACs are non-inferior compared to warfarin in the treatment of left ventricular thrombus in our population in Iowa, United States.CLINICAL IMPLICATIONS: This data emphasizes the need for a prospective randomized clinical trial to determine the most effective and safe treatment strategy for LV thrombus.
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