Abstract
BackgroundLeft ventricular thrombus (LVT) is a rare but dreaded complication during the acute phase of acute coronary syndrome (ACS). However, profound data on long‐term outcome and associated antithrombotic treatment strategies of this highly vulnerable patient population are scarce in current literature.MethodsPatients presenting with ACS were screened for presence of LVT and subsequently included within a prospective clinical registry. All‐cause mortality and the composite of major adverse cardiac events (MACE) and thromboembolic events were defined as primary and secondary endpoint.ResultsWithin 43 patients presenting with LVT, thrombus resolution during patient follow‐up was observed in 27 individuals (62.8%). Patients that reached a resolution of LVT experienced lower incidence rates of death (−23.9%; p = .022), MACE (−37.8%; p = .005), and thromboembolic events (−35.2%; p = .008). Even after adjustment for clinical variables, thrombus resolution showed an independent inverse association with all‐cause death with a hazard ratio (HR) of 0.14 (95% CI: 0.03–0.75; p = .021) and as well with MACE with a HR of 0.22 (95% CI: 0.07–0.68; p = .008) and thromboembolic events with a HR of 0.22 (95% CI: 0.06–0.75; p = .015). Triple antithrombotic therapy (TAT) with ticagrelor/prasugrel showed a strong and independent association with thrombus resolution with an adjusted HR of 3.25 (95% CI: 1.22–8.68; p = .019) compared to other strategies.ConclusionThe presented data indicate a poor outcome of ACS patients experiencing LVT. In terms of a personalized risk stratification, thrombus resolution has a strong protective impact on both all‐cause death and MACE with the potential to tailor treatment decisions—including an intensified antithrombotic treatment approach—in this patient population.
Highlights
Left ventricular thrombus (LVT) is a rare complication after acute coronary syndrome (ACS), especially occurring in patients presenting late with ST-elevation myocardial infarction (STEMI). 1 Incidence rates differ among the observational studies from 1.6% up to 39% indicating that many LVT cases might remain undetected. 2–7 This substantial variation in the incidence rate, is caused by varieties in the imaging modality used for diagnosis and the timing and frequency of screening
Thrombus formation is significantly associated with anterior myocardial infarction and confers an increased risk for thromboembolic events. 8–10 In the pre-thrombolytic era, these complications were described in approximately 10% of cases, whereas in the era of thrombolytic therapy embolic events occurred in 2–3% of cases. 8–10 Until now there is scarce evidence regarding the incidence of embolic events in patients treated by primary percutaneous coronary intervention (PCI) that receive dual anti-platelet therapy (DAPT) or even dual or triple anti-thrombotic therapy (DAT,Triple antithrombotic therapy (TAT))
The present study population covered a representative number of participants presenting with STEMI (n=26; 60.5%) and all patients developed LVT after anterior wall infarction
Summary
Left ventricular thrombus (LVT) is a rare complication after acute coronary syndrome (ACS), especially occurring in patients presenting late with ST-elevation myocardial infarction (STEMI). 1 Incidence rates differ among the observational studies from 1.6% up to 39% indicating that many LVT cases might remain undetected. 2–7 This substantial variation in the incidence rate, is caused by varieties in the imaging modality used for diagnosis and the timing and frequency of screening. Left ventricular thrombus (LVT) is a rare complication after acute coronary syndrome (ACS), especially occurring in patients presenting late with ST-elevation myocardial infarction (STEMI). 2–7 While the prognosis of patients presenting with LVT after ACS has been controversially discussed, it seems intuitive that individuals without thrombus resolution have an increased risk for cardiovascular events and mortality. Thrombus formation is significantly associated with anterior myocardial infarction and confers an increased risk for thromboembolic events (mostly cerebrovascular). Profound data on long-term outcome of this highly vulnerable patient population are scarce in current literature. We aimed to investigate the impact of LVT resolution and associated anti-thrombotic treatment strategies on patient’s outcome from a long-term perspective. Profound data on long-term outcome and associated antithrombotic treatment strategies of this highly vulnerable patient population are scarce in current literature
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