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February 25, 2026JAMA Cardiology
Low-Dose Rivaroxaban to Prevent Left Ventricular Thrombosis After Anterior Myocardial Infarction
Étienne PuymiratGilles SoulatBenoît LattucaClaire BouletiN. DelarcheFrançois RoubilleYves CottinDidier BressionNicolas CombaretÉdouard GerbaudLuc LorgisLoic BiereOlivier DubreuilElie MousseauxPhilippe Gabriel StegGuillaume CaylaAnne DruartJohanne SilvainJ G D DillingerGeorges JlGrégory DucrocqT. GenetJean-François MorelleGilles MontalescotLaurence BérardAlexandra RousseauMaxime SoenTabassome SimonNicolas DanchinAPERITIF study investigatorsCyril PrieurGrégoire RangéRomain GalletGilles Baronne RochetteCheikh KhelifaLaurent BonelloThomas CuissetAnis SaibOlivier VarenneVincent AuffretFahmi Ghanem
Key result
Low-dose rivaroxaban plus DAPT fails to reduce LV thrombus at 1 month in anterior STEMI.
- Difference -2.9%
- 95% CI -8.9% to 3.2%
- P=0.34
- n=560
Why the study?
Anterior acute myocardial infarction increases left ventricular thrombus risk, but the benefit and risk of adding an oral anticoagulant to DAPT to prevent it remain uncertain.
Does the addition of low-dose rivaroxaban to DAPT reduce the incidence of LV thrombus at 1 month in patients with anterior STEMI?
Key Points
- To evaluate the effect of low-dose rivaroxaban added to dual antiplatelet therapy on left ventricular thrombus incidence after anterior myocardial infarction.
- Multicenter, open-label, blinded-end point randomized clinical trial
- Participants had anterior ST-segment elevation myocardial infarction
- Randomized to receive either DAPT plus rivaroxaban or DAPT alone
- End point was presence of LV thrombus on cardiac MRI at 1 month.
- LV thrombus detected in 13.7% of rivaroxaban group vs 16.6% in DAPT alone group (P = .34)
- No significant differences in LV thrombus size or major cardiovascular events between groups
- Minor bleeding events more frequent in rivaroxaban group (16.4% vs 7.2%).
Study Design
Type
RCT (n=560)
Blinding
Open-label, blinded-end point
Multicenter
Yes
Structured PICO
Does the addition of low-dose rivaroxaban to DAPT reduce the incidence of LV thrombus at 1 month in patients with anterior STEMI?
P
Population
560 patients with anterior ST-segment elevation myocardial infarction (STEMI), mean age 61.1 years, 21.6% female, enrolled across 29 centers in France.
I
Intervention
Rivaroxaban 2.5 mg twice daily added to dual antiplatelet therapy (DAPT) for 4 weeks, started as soon as possible following completion of initial percutaneous coronary intervention or angiography.
C
Comparator
Dual antiplatelet therapy (DAPT) alone (aspirin ≤100 mg per day and either clopidogrel 75 mg per day or ticagrelor 90 mg twice a day).
O
Outcome
Presence of left ventricular (LV) thrombus on contrast-enhanced cardiac magnetic resonance imaging at 1 month.surrogate
Main Result
Effect estimate: Difference -2.9% (95% CI -8.9% to 3.2%)
Absolute Event Rate: 13.7% vs 16.6%
p-value: p=0.34
Adding low-dose rivaroxaban to DAPT for 4 weeks after anterior STEMI does not significantly reduce LV thrombus formation but increases minor bleeding.
Limitations
- Limited power of the study, meaning a modest effect cannot be excluded
- Limited power of the study
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Key expert perspectives
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“Ultimately, the addition of low-dose rivaroxaban to DAPT did not demonstrate a statistically significant reduction in LV thrombus formation at 1 month, but it did increase the risk of minor bleeding. Because event rates were slightly lower than expected, limiting the study's statistical power, we cannot completely rule out a modest effect—so these findings should be interpreted with that nuance in mind.”
Implication
Avoid routine rivaroxaban addition to DAPT after anterior STEMI; challenges DOAC expansion in post-MI guidelines and reinforces preference against triple therapy.
Abstract
Importance Anterior acute myocardial infarction is associated with increased risk of left ventricular (LV) thrombus. The benefit and risk of adding an oral anticoagulant to dual antiplatelet therapy (DAPT) in preventing LV thrombus remain uncertain. Objective To determine whether the addition of low-dose rivaroxaban to DAPT reduces the incidence of LV thrombus at 1 month in patients with anterior ST-segment elevation myocardial infarction (STEMI). Design, Setting, and Participants This multicenter, open-label, blinded–end point randomized clinical trial was performed in 29 centers in France. The trial was nested in the ongoing FRENCHIE (French Cohort of Myocardial Infarction Evaluation) registry. Between October 2021 and January 2023, patients with anterior STEMI were enrolled. The last date of participant follow-up was in March 2023. Data analysis was performed from September 2024 to July 2025. Interventions Patients were randomized to receive either DAPT plus rivaroxaban, 2.5 mg, twice daily for 4 weeks (n = 283) or DAPT alone (aspirin ≤100 mg per day and either clopidogrel, 75 mg per day, or ticagrelor, 90 mg twice a day [n = 277]), as soon as possible following completion of the initial percutaneous coronary intervention or angiography procedure. Main Outcomes and Measures The primary end point was presence of LV thrombus on contrast-enhanced cardiac magnetic resonance imaging at 1 month. Results Among 560 patients with anterior STEMI enrolled (mean [SD] age, 61.1 [11.6] years; 121 female patients [21.6%]), LV thrombus was detected in 38 patients (13.7%) receiving rivaroxaban and 47 patients (16.6%) with DAPT alone (difference, −2.9%; 95% CI, −8.9% to 3.2%; P = .34). No difference was observed between the 2 groups regarding the largest diameter of LV thrombus or the incidence of major adverse cardiovascular events. The incidence of major bleeding events (Bleeding Academic Research Consortium [BARC] ≥type 2) was also comparable (4 [1.5%] with DAPT plus rivaroxaban vs 2 [0.7%] with DAPT alone; difference, 0.7%; 95% CI, −1.3% to 3.1%), whereas minor bleeding events (BARC type 1) occurred more frequently in the DAPT plus rivaroxaban group (45 [16.4%] vs 20 [7.2%]; difference, 9.3%; 95% CI, 3.6%-14.8%). Conclusions and Relevance In this multicenter randomized clinical trial among patients with anterior STEMI, the addition of low-dose rivaroxaban to DAPT did not demonstrate a statistically significant reduction in LV thrombus formation at 1 month but did increase minor bleeding. Given the limited power of the study, these findings should be interpreted with caution, as a modest effect cannot be excluded. Trial Registration ClinicalTrials.gov Identifier: NCT05077683
Cite This Study
Puymirat et al. (2026) conducted an RCT in Anterior ST-segment elevation myocardial infarction (STEMI) (n=560). Rivaroxaban plus DAPT vs. DAPT alone was evaluated on Presence of left ventricular thrombus on contrast-enhanced cardiac magnetic resonance imaging at 1 month (Difference -2.9%, 95% CI -8.9% to 3.2%, p=0.34). Adding low-dose rivaroxaban to DAPT did not significantly reduce LV thrombus at 1 month in anterior STEMI compared to DAPT alone (13.7% vs 16.6%; 95% CI -8.9% to 3.2%; P=0.34).