Abstract
Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking. We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events. In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0months). 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 (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6months: p = 0.049; 12months: p = 0.044; 18months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001]. In the observational study, 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 associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.
Highlights
Left ventricular thrombus(LVT) can lead to serious complications after acute myocardial infarction(AMI), which is associated with a higher incidence of embolism(22.2%), death(18.9%), and major adverse cardiovascular events(37.1%)[1]
Triple therapy was started when left ventricular thrombus (LVT) was diagnosed by transthoracic echocardiography (TTE), and the use of Vitamin K Antagonists (VKA) or rivaroxaban was determined by physicians at that time
The exclusion criteria for LVT patients is that 1)rivaroxaban or VKA is currently being used for other diseases; 2)using other antithrombotic therapies in patients with LVT(i.e dabigatran, apixaban); 3)severe bleeding tendency; 4) hemorrhage or stroke occurred during hospitalization prior to baseline transthoracic echocardiography WBC (TTE); and 5)the quality of TTE was suboptimal, or it was not performed after admission
Summary
Left ventricular thrombus(LVT) can lead to serious complications after acute myocardial infarction(AMI), which is associated with a higher incidence of embolism(22.2%), death(18.9%), and major adverse cardiovascular events(37.1%)[1]. The current view is that LVT mostly formed after ST-Elevation myocardial infarction(STEMI). In previous studies on LVT, NOACs were usually considered as a whole and directly compared with VKA, which may be inappropriate due to the different anticoagulant mechanisms and pathways of NOACs. As one of the most widely used NOACs, safety and efficacy data of triple therapy with rivaroxaban in the setting of LVT after STEMI is limited. 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
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