Direct oral anticoagulant use in left ventricular thrombus

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

Circulation ◽

10.1161/circ.142.suppl_3.15803 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Nicholas Isom ◽

Zafar Ali ◽

Tarun Dalia ◽

Farhad Sami ◽

Uzair Mahmood ◽

...

Keyword(s):

Ischemic Stroke ◽

Natural History ◽

Ischemic Cardiomyopathy ◽

Academic Medical Center ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus ◽

Peripheral Embolization ◽

One Year

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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Efficacy and safety of direct oral anticoagulants for treatment of left ventricular thrombus; a systematic review

Acta Cardiologica ◽

10.1080/00015385.2021.1901024 ◽

2021 ◽

pp. 1-5

Author(s):

Dilpat Kumar ◽

F. N. U. Warsha ◽

Nicholas Helmstetter ◽

Vishal Gupta

Keyword(s):

Systematic Review ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Efficacy And Safety ◽

Ventricular Thrombus

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Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

Acta Cardiologica ◽

10.1080/00015385.2020.1858538 ◽

2021 ◽

pp. 1-10

Author(s):

Angkawipa Trongtorsak ◽

Sittinun Thangjui ◽

Jakrin Kewcharoen ◽

Natchaya Polpichai ◽

Ratdanai Yodsuwan ◽

...

Keyword(s):

Systematic Review ◽

Vitamin K ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Ventricular Thrombus

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A Case Series of Direct Oral Anticoagulants Use in Post-Infarction Left Ventricular Thrombus

Journal of the Bahrain Medical Society ◽

10.26715/jbms.33_2021_4_5 ◽

2021 ◽

Vol 33 (4) ◽

pp. 19-23

Author(s):

Tarique S. Chachar ◽

Nooraldaem Yousif ◽

Khurshid Ahmed ◽

Tajammul Hussain ◽

Haitham Amin

Keyword(s):

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Case Series ◽

Left Ventricular ◽

Left Ventricular Thrombus ◽

Off Label Use ◽

Mortality And Morbidity ◽

Ventricular Thrombus ◽

Current Guidelines

Left ventricular thrombus (LVT) is a known complication of acute myocardial infarction (AMI). Vitamin K antagonists such as Warfarin showed a reduction in associated mortality and morbidity and are indicated as anticoagulants of choice in current guidelines. Since their approval for clinical use, there has been a dramatic increase in off-label use of direct oral anti-coagulants (DOAC) for LVT. In this case series, the authors share their successful experience with DOAC in the treatment of LVT.

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