Thrombus perspectives: a comparative analysis of DOACs and warfarin

Abstract Background Left ventricular thrombus (LVT) secondary to left ventricular dysfunction represents a clinical challenge with profound implications for patient morbidity and mortality. A substantial body of evidence has emerged on this topic. However, much of it is derived from observational studies, which lack randomization and consequently impose significant limitations. In line with this, the 2023 guidelines for Acute Coronary Syndrome recommend the use of direct oral anticoagulants (DOACs) or warfarin for LVT management, yet this recommendation is based on a single randomized controlled trial (RCT) with limited data, hindering critical analysis. Purpose Conduct a systematic review and meta-analysis to assess the efficacy and safety profile of DOACs compared with warfarin in the management of LVT. Methods We systematically searched the Cochrane Controlled Register of Trials, EMBASE, and PubMed, focusing exclusively on RCTs. We sought studies comparing the use of DOACs, without restrictions on active principles, against warfarin. The primary outcomes were overall thrombus resolution and major bleeding events, while secondary endpoints included all-cause mortality and stroke. We pooled dichotomous data using odds ratios (OR) to describe effect sizes, employing the Mantel-Haenszel procedure within a random-effects model, with a 95% confidence interval. Heterogeneity was assessed statistically using the I² index (25% low, 25%-50% moderate, 50% high heterogeneity). Results Of the 290 records identified, 7 studies were included, providing data on 530 patients. Our meta-analysis revealed no significant differences in overall LVT resolution (pooled OR 1.52 0.97, 2.36, P = 0.92, I² = 0), despite a trend favoring the DOAC group. Additionally, no differences were observed between groups regarding major bleeding events (pooled OR 0.51 0.17, 1.52, P = 0.47, I² = 0). Furthermore, no differences were found regarding all-cause mortality (pooled OR 0.70 0.20, 2.42, P = 0.57, I² = 0) or stroke (pooled OR 0.56 0.12, 2.57, P = 0.42, I² = 0). Conclusions This meta-analysis indicates that DOACs are effective and safe alternatives to warfarin in the management of LVT. The advantages of DOACs, including their oral administration and ease of management, make them a more favorable option in contemporary clinical practice. Nevertheless, further large RCTs are necessary to further elucidate their role and optimize treatment strategies in this patient population.