Abstract
Current American College of Cardiology/American Heart Association guidelines for stroke or ST-elevation myocardial infarction recommend the use of oral vitamin K antagonists (VKAs) as a first-line anticoagulant. Although several studies have compared the use of direct oral anticoagulants (DOACs) to VKAs for left ventricular thrombus (LVT) anticoagulation therapy, they are small scale and have produced conflicting results. Thus, this meta-analysis was performed to aggregate these studies to better compare the efficacy and safety of DOACs with VKAs in patients with LVT. Cochrane Library, Google Scholar, MEDLINE, and Web of Science database searches through January 10, 2021 were performed. Eight studies evaluating stroke or systemic embolism (SSE), six studies for LVT resolution, and five studies for bleeding were included. There were no statistically significant differences in SSE (OR 0.89; 95% CI 0.46, 1.71; p = 0.73; I2 = 45%) and LVT resolution (OR 1.13; 95% CI 0.75, 1.71; p = 0.56; I2 = 1%) between DOAC and VKA (reference group) therapy. DOAC use was significantly associated with lower bleeding event rates compared to VKA use (OR 0.61; 95% CI 0.40, 0.93; p = 0.02; I2 = 0%). DOACs may be feasible alternative anticoagulants to vitamin K antagonists for LV thrombus treatment. Randomized controlled trials directly comparing DOACs with VKAs are needed.
Highlights
Left ventricular thrombus (LVT) development is common in patients with severe left ventricular (LV) dysfunction, often in the setting of acute anterior wall myocardial infarction (MI) and nonischemic cardiomyopathies, and is associated with increased risk of stroke or systemic embolism (SSE) [1,2,3]
A total of 122 articles were evaluated for eligibility, and eight studies were included for the final analysis (Fig 1) [11,12,13,15,18,19,20,21]
One study was excluded because the comparison of vitamin K antagonists (VKAs) with direct oral anticoagulants (DOACs) was not the primary study purpose and less than 5 patients on DOACs were included [10]
Summary
Left ventricular thrombus (LVT) development is common in patients with severe left ventricular (LV) dysfunction, often in the setting of acute anterior wall myocardial infarction (MI) and nonischemic cardiomyopathies, and is associated with increased risk of stroke or systemic embolism (SSE) [1,2,3]. DOACs vs warfarin in patients with LV thrombus our adherence to PLOS ONE policies on sharing data and materials. Pre-requisites for LVT formation include endothelial injury, hypercoagulability, and venous stasis, (i.e., Virchow’s triad), and can occur as early as within 24 hours to 3 months following MI [1]. The potential for LVT cerebral embolization persists in patients who develop chronic LV dysfunction. In heart failure with reduced ejection fraction (HFrEF), a hypercoagulable state is noted with increased incidence of LVT and higher risk of thromboembolism [6]
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