Abstract 15803: Effectiveness of Direct Oral Anticoagulant versus Warfarin in the Treatment of Left Ventricular Thrombus

Introduction: Left ventricular thrombus (LVT) is associated with a higher risk of ischemic stroke and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. Data on natural history and thrombus resolution with anticoagulation (AC), especially with DOACs is scarce. We studied the natural history of LVT with AC with emphasis on comparing warfarin and DOACs use. Methods: This is a single center, retrospective study conducted in an academic medical center. We identified patients (echocardiogram, CT or MRI) with a confirmed LVT study who were followed at our center. Chart review was conducted to collect clinical information at presentation and on follow up. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, mortality) were recorded. Thrombus resolution on follow up imaging was also recorded. Results: LVT was confirmed in a total of 110 patients. Mean age was 59±14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients (in remaining patients AC was thought to be contraindicated). Of those on long-term AC, 60 patients (63%) were treated with warfarin, 3 patients (3%) with enoxaparin and 32 patients (33%) with a DOACs. At one year follow up, 11 patients (10%) had a stroke while on any AC. Two of these patients had hemorrhagic stroke (both on warfarin) and 9 patients had ischemic stroke. Of those with ischemic stroke 7 were on warfarin and 2 patients on DOACs had ischemic strokes. Of those with ischemic stroke on warfarin, 71% had subtherapeutic INR. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p= 0.33). Total of 55 (57%) of patient started on AC had resolution of thrombus. 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p= 0.85). Conclusions: One year risk of stroke with LVT is high (10%) even with AC. Most patients with ischemic stroke on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients.

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Direct oral anticoagulant use in left ventricular thrombus

Thrombosis Journal ◽

10.1186/s12959-020-00242-x ◽

2020 ◽

Vol 18 (1) ◽

Cited By ~ 1

Author(s):

Zafar Ali ◽

Nicholas Isom ◽

Tarun Dalia ◽

Farhad Sami ◽

Uzair Mahmood ◽

...

Keyword(s):

Ischemic Stroke ◽

Ischemic Cardiomyopathy ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Significant Risk ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus ◽

Peripheral Embolization ◽

One Year

Abstract Left ventricular thrombus (LVT) is associated with a significant risk of ischemic stroke (IS) and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. We studied the natural history of LVT with anticoagulation (AC) with emphasis on comparing warfarin and DOAC use. In this single center study, we identified patients with a confirmed LVT. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, and thrombus resolution) were recorded. LVT was confirmed in a total of 110 patients. Mean age was 59 + 14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients. At 1 year follow up, 11 patients (10%) had a stroke while on any AC (2 had hemorrhagic stroke and 9 had IS). Of those with IS, 7 were on warfarin (71% of those had subtherapeutic INR) and 2 patients on DOACs had IS. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p = 0.33). 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p = 0.85). One-year risk of stroke with LVT is high (10%) even with AC. Most patients IS on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients.

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Non-vitamin K oral anticoagulants versus warfarin for treating left ventricular thrombus

European Heart Journal ◽

10.1093/eurheartj/ehab724.0903 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

K.K.H Kam ◽

J.S.K Chan ◽

A.P.W Lee

Keyword(s):

Vitamin K ◽

Oral Anticoagulants ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Safe Alternative ◽

Cumulative Mortality ◽

Ventricular Thrombus ◽

Secondary Outcomes ◽

One Year

Abstract Background Left ventricular thrombus (LVT) is associated with significant morbidity and mortality. Traditionally treated with anticoagulation by Warfarin, it is unclear if non-vitamin K oral anticoagulants (NOAC) are comparably efficacious and safe. Such data is also scarce in Asian patients. Purpose To compare the clinical efficacy and safety of NOAC with warfarin for managing LVT. Methods Clinical and echocardiographic records of all adult patients with echocardiography-confirmed LVT during January 2011 to January 2020 were retrieved. Any discontinuation of anticoagulation at one year was recorded. Outcomes of patients on NOAC were compared to those on warfarin. The primary outcomes were cumulative mortality and net adverse clinical events (NACE; any of cerebrovascular accident, systemic thromboembolism, intracranial haemorrhage, fatal bleeding, and overt bleeding). Secondary outcomes were complete LVT resolution and percentage reduction in LVT size at three-month follow-up, and the components of NACE. Results In total, 43 patients were included; 28 were treated by warfarin and 15 by NOAC, with mean follow-up periods of 20±12 months and 22±9 months respectively (p=0.522). Significantly fewer NACE were observed in the NOAC cohort (p=0.046; Figure 1), with a trend for lower cumulative mortality (p=0.058; Figure 2). There were no significant differences in the secondary outcomes. Additionally, given resolution of LVT, discontinuation of anticoagulation by one year was not associated with significantly different outcomes. Conclusion NOAC may be an efficacious and safe alternative to warfarin for treating LVT. Further studies are required to confirm our findings and delineate the optimal duration of anticoagulation. FUNDunding Acknowledgement Type of funding sources: Other. Main funding source(s): Hong Kong Special Administrative Region Government Health and Medical Research Fund Figure 1 Figure 2

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Abstract 15792: Etiology, Treatment and Outcomes in Patients With Left Ventricular Thrombus - Experiences From an African Center

Circulation ◽

10.1161/circ.142.suppl_3.15792 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Mohamed Hasham Varwani ◽

Mohamed Jeilan ◽

Jasmit Shah ◽

Leonard Ngunga

Keyword(s):

Ischemic Cardiomyopathy ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

University Hospital ◽

Treatment Practices ◽

Physician Review ◽

Lv Dysfunction ◽

Ventricular Thrombus ◽

One Year

Introduction: Left ventricular thrombus (LVT) may lead to thromboembolism and has been associated with increased morbidity and mortality. Little is known about the incidence, etiology and outcomes in patients with LVT in Africa. Objectives: To determine the etiology, treatment practices, rate of resolution and outcomes in patients with LVT in the region. Methods: A review of all echocardiograms performed in 2017 and 2018 at the Aga Khan University Hospital, Nairobi was carried out and patients with LVT identified. Physician review of charts was performed to document clinical characteristics and outcomes. Results: During the study period 100 patients with LVT were identified (1.3% of adult echoes). The mean LVEF was 28.5% (±11.0%) and 88% of the patients had an LVEF of less than 40%. Underlying etiology of LV dysfunction was post MI in 28%, chronic ischemic cardiomyopathy in 42% and non ischemic cardiomyopathy in 30%. In 15% of the patients a stroke or TIA predated the diagnosis of LVT. Long term anticoagulation was given to 92 patients. Among these, 37% received warfarin while 63% were treated with a DOAC (rivaroxaban (50%), dabigatran(7.6%) and apixaban(5.4%)). In 60% of the patients, anticoagulation was continued beyond a year. In patients with reassessment imaging (64%, median time 177 days), complete thrombus resolution was noted in 59.4%. One year follow-up data was available for 85 patients: 13 (15.3%) patients had died, 4 (4.7%) had suffered a stroke, and 8(9.4%) had a bleeding episode. Rates of thrombus resolution, stroke and bleeding were not significantly different among patients treated with warfarin and DOAC (Figure 1). Conclusions: We noted a high incidence of LVT compared to contemporary Western series. The majority of our patients were treated with DOACs. There were no significant differences in outcomes between patients treated with a DOAC and those receiving warfarin. Prospective evaluation on the efficacy and safety of DOACs for this indication is needed.

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Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Cardiology Research ◽

10.14740/cr1030 ◽

2020 ◽

Vol 11 (2) ◽

pp. 134-137

Author(s):

Khushboo K. Agarwal ◽

Steven Douedi ◽

Abbas Alshami ◽

Brook DeJene ◽

Robert G. Kayser

Keyword(s):

Critical Limb Ischemia ◽

Limb Ischemia ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus ◽

Rare Phenomenon ◽

Peripheral Embolization

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Distribution of left ventricular thrombus among patients with significantly impaired systolic function

New Emirates Medical Journal ◽

10.2174/0250688202666210519153051 ◽

2021 ◽

Vol 02 ◽

Author(s):

Ibrahim Abdullah Alranini ◽

Hatim Kheirallah ◽

Juan Jaime Alfonso ◽

Ahmed R. Al Fagih

Keyword(s):

Ischemic Cardiomyopathy ◽

Systolic Function ◽

Left Ventricular Systolic Function ◽

Regional Wall Motion ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Lv Function ◽

Variable Degree ◽

Ventricular Thrombus ◽

Study Results

Background: The prevalence of left ventricular (LV) thrombus as well as the distribution among patients with a variable degree of left ventricular systolic function impairment due to various etiologies is not well known. Objectives: To describe the distribution of left ventricular thrombus in relation to the underlying pathology, i.e., ischemic versus non-ischemic cardiomyopathy with ejection fraction (EF) below 45%. Methods: All echocardiography studies performed between January 2013 and September 2017 were reviewed, and only those with confirmed LV thrombus were included. The patient’s demographic, clinical characteristics, cardiac history, and echocardiographic parameters were obtained. The cohort was divided into 4 subgroups: 22 patients with EF of 36 - 45% (A), 114 with 26% - 35% (B), 99 with 16 - 25% (C) and 48 with 15% or less (D). Results: A total of 63,732 echocardiography study results were reviewed. Only 282 patients were proved to have LV thrombus with EF less than 45%. 217 (77%) patients had previous myocardial infarction, of which 212 (97.7%) were presented with anterior regional wall motion abnormality. 90 (32.7%) patients were found to have dilated left ventricle, while 41 (14.5%) were diagnosed with dilated cardiomyopathy (DCM). 37 (13.2%) patients had moderately severe to severe mitral regurgitation. It was observed that the highest distribution of LV thrombus was seen in group B (40.3%). Conclusion: The majority of LV thrombus distribution was seen in patients with EF between 26% to 35% due to ischemic cardiomyopathy. Conversely, in the cohort of non-ischemic cardiomyopathy, the majority were observed in those with severely impaired LV function.

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Clinical Outcomes in Patients with Ischemic versus Non-Ischemic Cardiomyopathy after Angiotensin-Neprilysin Inhibition Therapy

Journal of Clinical Medicine ◽

10.3390/jcm10214989 ◽

2021 ◽

Vol 10 (21) ◽

pp. 4989

Author(s):

Mohammad Abumayyaleh ◽

Christina Pilsinger ◽

Ibrahim El-Battrawy ◽

Marvin Kummer ◽

Jürgen Kuschyk ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Ischemic Cardiomyopathy ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Tachyarrhythmias ◽

Ventricular Ejection Fraction ◽

One Year ◽

The Impact

Background: The angiotensin receptor-neprilysin inhibitor (ARNI) decreases cardiovascular mortality in patients with chronic heart failure with a reduced ejection fraction (HFrEF). Data regarding the impact of ARNI on the outcome in HFrEF patients according to heart failure etiology are limited. Methods and results: One hundred twenty-one consecutive patients with HFrEF from the years 2016 to 2017 were included at the Medical Centre Mannheim Heidelberg University and treated with ARNI according to the current guidelines. Left ventricular ejection fraction (LVEF) was numerically improved during the treatment with ARNI in both patient groups, that with ischemic cardiomyopathy (n = 61) (ICMP), and that with non-ischemic cardiomyopathy (n = 60) (NICMP); p = 0.25. Consistent with this data, the NT-proBNP decreased in both groups, more commonly in the NICMP patient group. In addition, the glomerular filtration rate (GFR) and creatinine changed before and after the treatment with ARNI in both groups. In a one-year follow-up, the rate of ventricular tachyarrhythmias (ventricular tachycardia and ventricular fibrillation) tended to be higher in the ICMP group compared with the NICMP group (ICMP 38.71% vs. NICMP 17.24%; p = 0.07). The rate of one-year all-cause mortality was similar in both groups (ICMP 6.5% vs. NICMP 6.6%; log-rank = 0.9947). Conclusions: This study shows that, although the treatment with ARNI improves the LVEF in ICMP and NICMP patients, the risk of ventricular tachyarrhythmias remains higher in ICMP patients in comparison with NICMP patients. Renal function is improved in the NICMP group after the treatment. Long-term mortality is similar over a one-year follow-up.

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Left Ventricular Thrombus After Acute Decompensated Heart Failure in the Setting of Ischemic Cardiomyopathy

Cureus ◽

10.7759/cureus.4537 ◽

2019 ◽

Author(s):

Mohan Satish ◽

Naveen Vukka ◽

Dinesh Apala ◽

Toufik Mahfood Haddad ◽

Jaya Gupta

Keyword(s):

Heart Failure ◽

Ischemic Cardiomyopathy ◽

Acute Decompensated Heart Failure ◽

Decompensated Heart Failure ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus

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Dabigatran Effect on Left Ventricular Thrombus in a Patient with Acute Ischemic Stroke

Journal of Stroke ◽

10.5853/jos.2015.17.3.366 ◽

2015 ◽

Vol 17 (3) ◽

pp. 366-368 ◽

Cited By ~ 13

Author(s):

Kyuyoon Chung ◽

Young Min Paek ◽

Hye Jung Lee ◽

Keun-Sik Hong

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus

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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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