Direct oral anticoagulant use in left ventricular thrombus

Abstract

Left ventricular thrombus (LVT) is associated with a significant risk of ischemic stroke (IS) and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. We studied the natural history of LVT with anticoagulation (AC) with emphasis on comparing warfarin and DOAC use. In this single center study, we identified patients with a confirmed LVT. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, and thrombus resolution) were recorded. LVT was confirmed in a total of 110 patients. Mean age was 59 + 14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients. At 1 year follow up, 11 patients (10%) had a stroke while on any AC (2 had hemorrhagic stroke and 9 had IS). Of those with IS, 7 were on warfarin (71% of those had subtherapeutic INR) and 2 patients on DOACs had IS. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p = 0.33). 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p = 0.85). One-year risk of stroke with LVT is high (10%) even with AC. Most patients IS on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients.

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

“…Nine studies reported bleeding events 6,9,16,19-22,24,25 , 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 ).…”

“…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 ).…”

“…Ten studies reported the occurrence of SSE 5-9,20-25 . The NOACs group and VKAs group did not show a significant difference in the risk of SSE (RR:0.96, 95% CI: 0.80-1.16, P = 0.69; I 2 = 0%, Figure 2A ).…”

“…Subgroup analysis for follow-up duration (P interaction = 0.07), sample size (P interaction = 0.09), concomitant antiplatelet medication (P interaction = 0.48) and primary causes of LVT (P interaction = 0.09) showed a consistently similar effect of NOACs and VKAs ( Table 2 ). Eight studies reported the outcome of strokes 6,9,19-22,24,25 . NOACs users showed lower risk of stroke compared with VKAs users (RR: 0.68, 95% CI: 0.68-1.00, P < 0.05, Figure 2B ).…”

“…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 ).…”