Efficacy and safety of direct oral anticoagulants for treatment of left ventricular thrombus

Abstract Background Left ventricular (LV) thrombus is a complication of acute myocardial infarction and heart failure that confers an increased risk of thromboembolic events. Although there has been some updates in professional society recommendations, the standard of care for treatment of LV thrombus remains use of Vitamin K antagonists (VKA) due to their efficacy in thrombus resolution and prevention of thromboembolic events. While direct oral anticoagulants (DOAC) have become a preferred over VKA for treatment of other cardiac conditions necessitating anticoagulation, their role for treatment of LV thrombus remains secondary at this time due to limited available evidence. Purpose The purpose of this meta-analysis is to compare the efficacy and safety of DOAC vs VKA for the treatment of LV thrombus. Methods A literature search was conducted to identify studies that directly assessed DOAC and VKA use in treatment of LV thrombus and their association with clinical and safety endpoints. Clinical endpoints of interest included risk of cerebrovascular accident (CVA), any systemic embolism, all-cause mortality, and persistent LV thrombus. Safety endpoints included any bleeding, intracranial bleeding, and GI bleeding. The search included the following databases: PubMed, Web of Science, and Embase. TriNetX and registry studies were excluded. Results A total of 26 studies and 4272 patients were included (1381 treated with DOAC, 2891 treated with VKA). The mean follow-up duration was 15.3 months (ranging 3 to 28.4 months), mean age was 60.3 years old, 79.6% were men, and mean left ventricular ejection fraction was 33.6%. Compared to VKA, use of DOAC for treatment of LV thrombus was associated with a significantly lower risk of CVA (OR 0.69, 95% CI 0.59-0.80;p=0.02). There was a non-statistically significant trend toward lower risk of any systemic embolic event with DOAC use (OR 0.59, 95% CI 0.33-1.07;p=0.10). There was no difference in risk of all-cause mortality or persistence of LV thrombus with treatment using DOAC versus VKA (OR 0.86, 95% CI 0.58-1.27;p=0.43; OR 1.01, 95% CI 0.85-1.20;p=0.91). There was no difference in risk of any bleeding, intracranial bleeding, or GI bleeding in patients with LV thrombus treated with DOAC compared to VKA (OR 0.96, 95% CI 0.69-1.35;p=0.84; OR 0.75, 95% CI 0.41-1.36;p=0.48; OR 1.00, 95% CI 0.74-1.36;p=0.98). The heterogeneity for all analyses in this study was low (I2=0% for all endpoints except any bleeding, where I2=21%). Conclusions Compared to VKA, use of DOAC is associated with lower risk of CVA, a trend toward lower risk of any systemic embolism, and no difference in risk of all-cause mortality or persistence of LV thrombus. Use of DOAC is also not associated with any increased risk for bleeding events. Additional high quality studies are required to further solidify the role of DOAC for treatment of LV thrombus.Figure 1 Figure 2