Assessment of non‐vitamin K antagonist oral anticoagulants for the management of left ventricular thrombus

Abstract

Although several studies have assessed the effect of non‐vitamin K antagonist oral anticoagulants (NOACs) relative to that of vitamin K antagonists (VKAs) in patients with left ventricular thrombus, the results remain controversial. Herein, a meta‐analysis was performed to compare the effectiveness and safety of NOACs versus VKAs for the treatment of left ventricular thrombus. We systematically searched the Cochrane Library, PubMed and Embase databases until November 2020 for studies that compared the effects of NOACs versus VKAs in patients with left ventricular thrombus. The treatment effects were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and pooled by a random‐effects model. Seven retrospective studies involving 865 patients with left ventricular thrombus (266 NOAC and 599 VKA users) were included. The pooled analysis suggested no difference in the rate of thrombus resolution between the NOAC and VKA groups (OR = 0.83, 95% CI 0.61–1.13). There were also no differences in the rates of stroke or systemic embolism (OR = 0.62, 95% CI 0.20–1.97), bleeding events (OR = 0.73, 95% CI 0.37–1.45), or all‐cause death (OR = 0.92, 95% CI 0.50–1.69) between patients treated with NOACs and those treated with VKAs. In addition, the rates of thrombus resolution, stroke or systemic embolism, bleeding events, and all‐cause death between NOAC‐ and warfarin‐treated patients were also similar. Our current evidence suggested that NOAC and VKA users had similar rates of thrombus resolution and clinical outcomes among patients with left ventricular thrombus. Further large‐scale prospective studies should confirm our results.

Different Oral Antithrombotic Therapy for the Treatment of Ventricular Thrombus: An Observational Study from 2010 to 2019

“…Second, the short duration or small dosage of anticoagulation could produce low efficacy of anticoagulation, and some patients who were already on oral anticoagulation might have a poor adherence such as bad monitoring of INR or irregular treatment. Otherwise, while most studies mainly compared the efficacy and safety between NOACs and VKAs [12][13][14][15][16][17][18][19][20][21][22][23] (Table S6), our study firstly offered a new idea towards exploring APT in VT treatment. Our study showed that the rates of bleeding, embolism, and all-cause death were similar among the NOACs, VKAs, and APT groups within a 12 months' follow-up.…”

“…2017 European guidelines also recommended that STEMI patients with left VT should maintain anticoagulation therapy for up to 6 months under the guidance of repeated imaging (Class II a, level C evidence) [11]. Up to date, quite a few studies reported that NOACs had comparable safety and efficacy outcomes in the treatment of VT [12][13][14][15][16][17][18][19][20][21][22][23][24]. Michael et al (2021) conducted a metaanalysis to compare NOACs to VKAs for the treatment of left ventricular thrombus, including a total of 18 studies with 2666 patients, and their result showed that NOACs had less 37% risk of stroke than VKAs, while no significances were observed in thrombus resolution, systemic embolism, bleeding, or all-cause death events.…”

Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants

“…Результаты комбинированной конечной точки по инсульту и периферической эмболии также показали превосходство ПОАК над варфарином (p=0,0001) [44]. По данным большого числа мета-анализов и систематических обзоров, ПОАК не уступают АВК по эффективности и безопасности при тромбозе ЛЖ и могут служить им достойной альтернативой [45][46][47][48][49][50][51]. Стоит отметить, что из-за ограниченного количества статей и рандомизированных исследований встречаются мета-анализы с противоречивыми выводами.…”

Contemporary Review of the Management of Left Ventricular Thrombus

“…Several meta-analyses have similarly found no significant difference in clinical outcomes. [5][6][7][8][9][10][11][12][13] In addition, several observational studies have suggested that DOACs may be associated with a faster rate of resolution compared with warfarin. 18,20,29,30,46 Thus, DOACs may be a reasonable alternative to warfarin, but larger RCTs are needed to validate this statement.…”

“…More recently, however, there has been increasing evidence to support the use of direct oral anticoagulants (DOACs), with several studies showing comparable efficacy and safety between them. [5][6][7][8][9][10][11][12][13] Although the initial treatment options for LVT are better established, the management of patients after the initial duration of anticoagulation is more complex and varied. After a period of initial anticoagulation, subsequent repeat imaging is often done via transthoracic echocardiogram (TTE) with/ without contrast and occasionally cardiac MRI (CMR) to assess for resolution of LVT.…”