Abstract
BackgroundAlthough several meta-analyses have compared efficacies of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) for treatment of left ventricular thrombus (LVT), those meta-analyses included no single-arm studies.Methods and resultsPubMed, Scopus, and the Cochrane Library databases were searched for articles investigating thrombus resolution, stroke, any thromboembolism, major bleeding, any bleeding, or all-cause death in LVT treated with VKAs or DOACs, and single-class meta-analyses were also included (PROSPERO database, CRD42021230849). Event rates were pooled using a random effects model. Meta-regression analysis was performed to explore factors that may influence outcomes. 2,612 patients from 23 articles were included (VKAs: 2,004, DOACs: 608). There were no significant differences between VKAs and DOACs in the frequency of thrombus resolution (VKAs: 0.75 [95% confidence interval; 0.67 to 0.81], DOACs: 0.75 [0.67 to 0.82]), stroke (VKAs: 0.06 [0.04 to 0.10], DOACs: 0.02 [0.01 to 0.01]), any thromboembolism (VKAs: 0.08 [0.05 to 0.13], DOACs: 0.03 [0.01 to 0.10]), major bleeding (VKAs: 0.06 [0.04 to 0.09], DOACs: 0.03 [0.01 to 0.06]), any bleeding (VKAs: 0.08 [0.05 to 0.12], DOACs: 0.08 [0.06 to 0.10]), and all-cause death (VKAs: 0.07 [0.04 to 0.13], DOACs: 0.09 [0.05 to 0.16]). Meta-regression analysis revealed that increased duration of follow-up was associated with lower-rates of stroke (estimate: -0.040, p = 0.0495) with VKAs, but not with DOACs. There was significant publication bias for thrombus resolution, stroke, any thromboembolism, any bleeding, and all-cause death.ConclusionsEfficacy and adverse outcomes of therapy with DOACs and VKAs do not differ. Randomized controlled trials are needed to determine the optimal anticoagulant strategy.
Highlights
Left ventricular thrombus (LVT) present serious complications in patients with stagnant left ventricular (LV) blood flow, patients who have suffered a post-myocardial infarction or heart failure (HF) with severely reduced LV systolic function
For treatment of left ventricular thrombus (LVT), European Society of Cardiology guidelines for the management of acute myocardial infarction in patients with ST-segment elevation recommend the use of oral anticoagulants up to 6 months, and American College of Cardiology/American Heart Association guidelines state that anticoagulant therapy with a vitamin K antagonist (VKA) is reasonable for patients with ST-segment elevation MI and asymptomatic LVT [5, 6]
In randomized controlled trials, direct oral anticoagulants (DOACs) have demonstrated some advantages over VKAs for a variety of thromboses, including acute pulmonary thromboembolism [8,9,10], cancer-related venous thromboembolism (VTE) [11,12,13], non-valvular atrial fibrillation (AF) with coronary artery disease [14], and AF with bioprosthetic mitral valves [15]
Summary
Left ventricular thrombus (LVT) present serious complications in patients with stagnant left ventricular (LV) blood flow, patients who have suffered a post-myocardial infarction or heart failure (HF) with severely reduced LV systolic function. For treatment of LVT, European Society of Cardiology guidelines for the management of acute myocardial infarction in patients with ST-segment elevation recommend the use of oral anticoagulants up to 6 months, and American College of Cardiology/American Heart Association guidelines state that anticoagulant therapy with a vitamin K antagonist (VKA) is reasonable for patients with ST-segment elevation MI and asymptomatic LVT [5, 6]. In randomized controlled trials, DOACs have demonstrated some advantages over VKAs for a variety of thromboses, including acute pulmonary thromboembolism [8,9,10], cancer-related VTE [11,12,13], non-valvular AF with coronary artery disease [14], and AF with bioprosthetic mitral valves [15]. Several meta-analyses have compared efficacies of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) for treatment of left ventricular thrombus (LVT), those meta-analyses included no single-arm studies
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