Rivaroxaban versus Vitamin K Antagonists (Warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation Myocardial Infarction

Abstract

Background: Left ventricular thrombus(LVT) can lead to serious complications, and mostly formed after ST-Elevation myocardial infarction(STEMI). The Off-label use of new oral anticoagulants(NOACs) in the triple therapy of LVT after STEMI has increased in the past few years. As one of the most widely used NOACs, the data of safety and efficacy of rivaroxaban in LVT after STEMI is limited and warrants continued exploring.Methods: We conducted a retrospective cohort study involving STEMI patients underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we evaluated the efficacy and safety of rivaroxaban plus DAPT therapy associated with thrombus resolution and clinical adverse events, compared with triple therapy with VKA. Results: In 1,335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period[HR:1.57(95%CI 0.89-2.77), p=0.096; Adjusted HR:1.70(95%CI 0.90-3.22), p=0.104]. When the analysis focused on LVT resolution at different time points during the follow-up period, triple therapy with rivaroxaban showed quicker resolution than with VKA(6months:p=0.049; 12months:p=0.044; 18months:p=0.045). Meanwhile, similar risks of ISTH bleeding were recorded in both groups, with no difference between the two groups(Rivaroxaban 6.1% vs VKA 9.7% , p=0.444). Fewer net adverse clinical events(NACE) were observed in the rivaroxaban group compared with the VKA group[Rivaroxaban 24.2% vs VKA 58.1%; HR:0.31(95%CI 0.14-0.68), p=0.003; Adjusted HR: 0.23(95%CI 0.09-0.57), p=0.001].Conclusions: This observational study suggests triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was accompanied with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombus: An Updated Meta-Analysis of Cohort Studies and Randomized Controlled Trials

“…), according to the inclusion and exclusion criteria. Ultimately, 12 cohort studies 6–10,17–23 and 3 RCTs 11–13 met the inclusion criteria and were included in our systematic review (Fig. 1).…”

“…There was no difference between DOACs and VKAs regarding LVT resolution when data from 13 studies [7][8][9][10][11][12][17][18][19][20][21][22][23] were pooled (RR = 1.01; 95% CI, 0.93 to 1.09, P = 0.48, I 2 = 0%). Similar results were obtained by subgroup analysis based on different study designs (Fig.…”

“…2C). Regarding all-cause mortality, 7 studies (5 cohort studies and 2 RCTs, 714 patients) 9,10,12,13,17,21,23 were included in the meta-analysis. No significant difference was detected between DOACs and VKAs in LVT treatment (RR = 0.9, 95% CI, 0.58 to 1.4, P = 0.65, I 2 = 0%) (Fig.…”

“…2A). Fifteen articles [6][7][8][9][10][11][12][13][17][18][19][20][21][22][23] reported on stroke and/or systematic embolic events. The pooled RR for stroke and/or systematic embolic events was 0.87 (95% CI, 0.11 to 1.55, P = 0.2), but this analysis demonstrated substantial heterogeneity (I 2 = 67.2%) (Fig.…”

“…4,5 Recently, several cohort studies and 3 randomized controlled trials (RCTs) have been completed. [6][7][8][9][10][11][12][13] Therefore, we conducted an updated systematic review and metaanalysis to compare the safety and efficacy of DOACs and VKAs in patients with LVTs.…”