NOVEL ORAL ANTICOAGULANTS VERSUS VITAMIN K ANTAGONISTS FOR PATIENTS WITH LEFT VENTRICULAR THROMBUS: A SYSTEMATIC REVIEW AND META-ANALYSIS

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.

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Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248420977567 ◽

2020 ◽

pp. 107424842097756

Author(s):

Carolina Saleiro ◽

João Lopes ◽

Diana De Campos ◽

Luís Puga ◽

Marco Costa ◽

...

Keyword(s):

Systematic Review ◽

Vitamin K ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Left Ventricular ◽

Systemic Embolism ◽

Bleeding Events ◽

Ventricular Thrombus

Background: Current guidelines recommend vitamin K antagonists (VKAs) for left ventricular thrombus (LVT) resolution. Direct oral anticoagulants (DOACs) are increasingly evaluated as alternatives to the standard of care in anticoagulation. Methods: We performed a systematic review and meta-analysis to assess the use of DOACs vs VKAs for LVT treatment. The occurrence of LVT resolution, systemic embolism (SE) or stroke, and bleeding events were compared during follow-up using random-effects analysis. Results: The 5 included studies were all observational (a total of 828 patients). Of these, 284 patients (34%) were treated with DOACs, and 544 (66%) treated with VKAs. Thrombus resolution was similar for both methods (pooled odds ratio [OR], 0.91; 95% CI, 0.47-1.75; I2 = 63%; P = .78). The incidence of SE or stroke was also similar (pooled OR, 1.59; 95% CI, 0.85-2.97; I2 = 0%; P = .14). Clinically relevant bleeding incidence was similar for both groups (pooled OR, 0.66; 95% CI, 0.31-1.40; I2 = 0%; P = .28), although all bleeding events were less frequent in the DOAC group (pooled OR, 0.49; 95% CI, 0.26-0.90; I2 = 0%; P = .02). Conclusion: Our systematic review and meta-analysis suggests DOACs were as effective as VKAs for LVT resolution, with a similar risk of systemic embolism/stroke and clinically relevant bleeding. These results, obtained from observational studies, are not definitive and hence randomized controlled trials are needed. Nevertheless, our analysis identifies key experimental features required in future studies.

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Novel Oral Anticoagulants versus Vitamin K Antagonists for Patients with Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

10.1101/2020.12.08.20246330 ◽

2020 ◽

Author(s):

Runzhen Chen ◽

Jinying Zhou ◽

Chen Liu ◽

Peng Zhou ◽

Jiannan Li ◽

...

Keyword(s):

Vitamin K ◽

Observational Studies ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Similar Efficacy ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Efficacy And Safety ◽

Ventricular Thrombus

AbstractBackgroundAlthough vitamin K antagonists (VKAs) are recommended as first-line anticoagulants for patients with left ventricular thrombus (LVT), accumulating evidence suggests novel oral anticoagulants (NOACs) could be safe alternatives for VKAs. Efficacy and safety of NOACs should be assessed to justify their usage for LVT patients.DesignWe performed a meta-analysis of observational studies to evaluate the efficacy and safety of NOACs as compared to VKAs in LVT patients.MethodsPubMed and EMBASE databases were searched for articles published until November 12, 2020. Two reviewers independently extracted relevant information from articles and assessed the study quality. Pooled effects were estimated using Mantel–Haenssel method and presented as risk ratios (RR) using fixed-effect model. Reporting followed the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) guideline.ResultsA total of 2467 LVT patients from 13 studies were included. Compared with VKAs, NOACs showed similar efficacy in prevention of stroke or systemic embolism (RR: 0.96, 95% confidence interval [CI]:0.80-1.16, P = 0.68) and thrombus resolution (RR: 0.88, 95% CI: 0.72-1.09, P = 0.20), but significantly reduced the risk of stroke (RR: 0.68, 95% CI: 0.47-1.00, P < 0.05). For safety outcomes, NOACs users showed similar risk of any bleedings (RR: 0.94, 95% CI: 0.67-1.31, P = 0.70), but lower risk of clinically relevant bleedings (RR: 0.35, 95% CI: 0.13-0.92, P = 0.03) compared with VKAs users.ConclusionsCompared with VKAs, NOACs acquired similar efficacy and safety profile for patients with LVT, but could reduce the risk of strokes and clinically relevant bleedings.

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The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction

European Heart Journal - Cardiovascular Pharmacotherapy ◽

10.1093/ehjcvp/pvaa096 ◽

2020 ◽

Cited By ~ 7

Author(s):

Daniel A Jones ◽

Paul Wright ◽

Momin A Alizadeh ◽

Sadeer Fhadil ◽

Krishnaraj S Rathod ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Vitamin K ◽

Oral Anticoagulants ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Novel Oral Anticoagulants ◽

Secondary Outcome ◽

Ventricular Thrombus

Abstract Aim Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI. Methods and results This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388). Conclusion These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.

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