Cracking the clot: the RIVAWAR trial challenges warfarin’s reign in left ventricular thrombus post-acute coronary syndrome

Left ventricular thrombosis (LVT) is a severe complication that often arises in patients with left ventricular systolic dysfunction, particularly within 1–14 days after a ST-segment elevation myocardial infarction (STEMI), and is associated with increased risks of stroke, embolization, and mortality.1,2 Despite modern reperfusion therapy, the prevalence of LVT remains notable, ranging from 2 to 22%.3,4 It is more frequent in patients with anterior STEMI and in patients with severe ventricular dysfunction and varies based on the imaging modality employed for detection.5–7 Vitamin K antagonists, such as warfarin, have been the standard treatment for LVT, though they require monitoring and have dietary interactions.8In contrast, direct oral anticoagulants, including rivaroxaban, have gained attention as alternatives, offering advantages such as fewer food and drug interactions, a lower risk of bleeding, and no requirement for routine laboratory monitoring.9 The 2023 ESC Guidelines for management of acute coronary syndromes (ACS) recommend that oral anticoagulation therapy [warfarin or direct anticoagulants (DOAC)] should be considered for 3–6 months in patients with confirmed LVT (class IIa, level of evidence C).10 Nonetheless, the evidence supporting DOAC use for LVT, particularly in the context of ACS, remains limited.11,12