Successful Resolution of Left Ventricular Thrombus after ST-Elevation Myocardial Infarction by Edoxaban in a Patient with High Bleeding Risk.

Abstract

Left ventricular (LV) thrombus is a relatively rare complication of myocardial infarction, with incidence ranged from 2.9% to 15% in different population.1 It is potentially catastrophic since it may lead to embolic cerebrovascular accident. Patients with LV thrombus may have worse prognosis and quality of life. Risk factors include anterior ST elevation myocardial infarction (STEMI), large infarct size, LV aneurysm, suboptimal revascularization [those with Thrombolysis In Myocardial Infarction (TIMI) 0-1 flow], and cardiac arrest. Anticoagulant therapy with a vitamin K antagonist in patients with STEMI is suggested, with class IIa recommendation for asymptomatic LV mural thrombi and class IIb recommendation for LV anterior apical akinesis or dyskinesia at a level of evidence of C, in the American College of Cardiology/American Heart Association (ACC/ AHA) guidelines on the management of STEMI.2 However, warfarin is prone to multiple adverse drug effects, multiple drug and food interaction, and difficulties in maintaining time-in-the-therapeutic-range (TTR) of INR, especially in the Asian with atrial fibrillation.3 In one study, embolic events related to LV thrombus can be reduced when TTR ≥ 50%, however, it is difficult to maintain in many patients, therefore they are exposed to complications related to suboptimal TTR control.4 Dual antiplatelet therapy is at risk of bleeding and its management is mentioned specifically.5 Moreover, triple therapy with warfarin have an unacceptable higher bleeding risk. In the WOEST trial, even though bleeding risk can be lowered by combination using clopidogrel and warfarin only, the risk is still high (19.4% vs. 44.4%). In the current era, non-vitamin K antagonist oral anticoagulants (NOAC) appear to have similar efficacy, better safety, and fewer drug and food interactions than warfarin for those with non-valvular atrial fibrillation and with venous thromboembolism. Here, we demonstrate a case with successful resolution of LV thrombus by edoxaban.