Efficacy and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Left ventricular thrombus (LVT) is a serious complication associated with myocardial infarction and cardiomyopathy. While vitamin K antagonists (VKAs) have been the standard treatment, direct oral anticoagulants (DOACs) offer potential advantages. This meta-analysis compares the efficacy and safety of DOACs versus VKAs in patients with LVT. We conducted a systematic search of PubMed, Excerpta Medica database (Embase), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2025. Studies comparing DOACs with VKAs in adult patients with LVT were included. The primary outcome was LVT resolution; secondary outcomes included stroke or systemic embolism (SSE) and bleeding events. Random-effects models were used to calculate pooled risk ratios (RRs) with 95% confidence intervals. Thirty-five studies (five RCTs and 30 observational) with 4,823 patients were included. LVT resolution was comparable between DOACs and VKAs (RR: 1.04, 95% CI: 0.99-1.10, I² = 30%). Risk of SSE showed no significant difference (RR: 0.91, 95% CI: 0.80-1.03, I² = 11%). DOACs were associated with significantly lower bleeding risk (RR: 0.87, 95% CI: 0.81-0.94, I² = 0%). Subgroup analyses by study design showed consistent findings. DOACs demonstrated comparable efficacy to VKAs for LVT resolution and stroke prevention while offering a superior safety profile with lower bleeding risk. These findings suggest DOACs may be a viable alternative to VKAs in LVT management, though large-scale randomized trials are needed to confirm these results and establish optimal dosing strategies.