DOACs vs Warfarin for Post-myocardial Infarction Left Ventricular Thrombus: A GRADE-assessed Meta-Analysis With Trial Sequential Analysis of Randomized Trials

Background and PurposeCurrent AHA and ACC guidelines warrant studies comparing direct oral anticoagulant (DOAC) and warfarin for post-myocardial infarction (MI) left ventricular thrombus (LVT). DOAC is increasingly considered due to its minimal monitoring requirement. However, DOAC efficacy in LVT resolution remains uncertain. We aim to evaluate the efficacy and safety of DOAC versus warfarin in post-MI LVT.MethodsWe searched Medline/PubMed, Scopus, Web of Science, and Cochrane. Library databases from inception up to August 2025. The primary outcome was LVT resolution. Secondary outcomes included all-cause death, stroke, and major bleeding rates.ResultsFour RCTs encompassing 396 patients (240 DOAC, 156 warfarin) were included. LVT resolution occurred in 90.0% of DOAC patients versus 86.5% in warfarin patients, with no significant difference (RR 0.99, 95% CI 0.94-1.06, p=0.84). Subgroup analysis revealed comparable outcomes for both rivaroxaban and apixaban versus warfarin. Stroke rates were higher in DOAC compared to warfarin but not statically significant between groups (2.5% vs 1.2%, RR 1.37, 95% CI 0.15-12.95). Similarly, all-cause mortality (3.3% vs 1.9%) and major bleeding (1.6% vs 1.9%) showed no significant differences.ConclusionDOACs demonstrate comparable efficacy and safety to warfarin for post-MI LVT management, with similar rates of thrombus resolution and complications. However, TSA indicates that current evidence is underpowered, and further large-scale randomized trials are required to confirm these findings.