Direct oral anticoagulants for the treatment of left ventricular thrombosis: an updated systematic review and meta-analysis

Abstract

Aims This meta-analysis aims to compare direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in the setting of left ventricular thrombosis (LVT). Method and ResultsWe systematically searched MEDLINE, Cochrane Library, Biomed Central and Web of Science for trials comparing DOACs versus VKAs in the setting of LVT and reporting outcome data on thrombosis resolution, stroke and bleeding. Fourteen studies were finally selected. The Mantel-Haenszel method with a random effect model was used for the pooled analysis. The primary outcome was the occurrence of LVT resolution. The secondary outcomes were the occurrence of stroke or bleeding during treatment. One thousand three hundred and thirty-two patients were included in the analysis for the primary outcome. Of these, 424 were treated with DOACs and 908 with VKAs. The pooled odds ratio (OR) for the primary outcome was 1.00 [95% confidence interval (95% CI) 0.77-1.31, I 2 0.0%], reflecting equal effect in terms of thrombus resolution. Overall, 2290 patients, 608 on DOACs and 1682 on VKAs were included in the analysis of stroke occurrence, showing reduced risk of events in patients treated with DOACs (pooled OR 0.58, 95% CI 0.36-0.93; I 2 0.0%) as well as for bleeding occurrence (number of patients included 2139; pooled OR 0.64, 95% CI 0.44-0.94; I 2 0.0%). ConclusionCompared with VKAs, we found DOACs to have similar efficacy on thrombus resolution and favorable effects on stroke reduction and bleedings. DOACs should be considered as an alternative treatment for LVT. Large prospective randomized clinical trials are needed to confirm this exploratory finding.

Another meta-analysis on novel oral anticoagulants for left ventricular thrombus: when enough is enough?

“…Furthermore, currently available evidence suggests there might be a difference not only among safety and efficacy outcomes accomplishments of specific NOAC, for example with apixaban better at preventing major bleeding, [12][13][14][15] but also in NOAC effectiveness depending on the followup duration. 3,14 In this regard, interesting differences in NOAC and VKA clinical outcomes, for example thrombus resolution and death, appear to emerge in a strict follow-up time-dependent fashion only, as displayed in the study by Huang et al, 3 and in the study by Camaj et al 5 Outcome exploratory analysis based on individual anticoagulants or varying follow-up, carried out by Serenelli et al, 6 impacts, albeit mildly, on effects, and these findings might warrant further research on these potentially relevant features.…”

“… 7–11 Serenelli et al 6 argue that their analysis updates the results of previously published ones, thanks to the inclusion of data from recently available studies. Including in the results of Serenelli et al , 6 a separate analysis of newly released studies alone might have helped accomplishing both a corroboration and a greater relevance of the outcomes. Furthermore, currently available evidence suggests there might be a difference not only among safety and efficacy outcomes accomplishments of specific NOAC, for example with apixaban better at preventing major bleeding, 12–15 but also in NOAC effectiveness depending on the follow-up duration 3,14 .…”

“…1). 7–11 Serenelli et al 6 argue that their analysis updates the results of previously published ones, thanks to the inclusion of data from recently available studies. Including in the results of Serenelli et al , 6 a separate analysis of newly released studies alone might have helped accomplishing both a corroboration and a greater relevance of the outcomes.…”

“…Overall, the meta-analysis by Serenelli et al 6 appears as a solid work, although it needs to be considered as an additional piece in the bigger picture of currently available partial and evocative evidence regarding the role of NOAC in LVT treatment. At present, guidelines stemming from international professional societies do not recommend NOAC use in LVT setting guidelines, and the same applies to national regulatory agencies.…”

“…In previous issue of this journal, Serenelli et al 6 precisely report their meta-analysis comparing NOAC versus VKA in patients with LVT. According to their results, NOAC were more effective than VKA in reducing the risk of stroke (pooled odds ratio = 0.58) and treatment-associated bleeding (pooled odds ratio = 0.64), but not in resolving the LVT.…”