Left Ventricular Thrombus Despite Prescribed Direct Oral Anticoagulant Therapy in Chronic Heart Failure With Reduced Ejection Fraction: A Case Report and Review of Risk Stratification

Left ventricular thrombus (LVT) remains a clinically important complication associated with increased risks of systemic thromboembolism, ischemic stroke, and adverse cardiovascular outcomes. The optimal duration of anticoagulation treatment remains difficult to establish, and it should be individualized depending on patient characteristics. We present the case of a 65-year-old man with a history of coronary artery disease (CAD) status post-myocardial infarction, who underwent coronary bypass graft surgery, ischemic cardiomyopathy, chronic heart failure with reduced ejection fraction (HFrEF) with left ventricular ejection fraction of 30%-35% diagnosed in 2022, atrial flutter status post-ablation, and chronic kidney disease stage II who was found to have LV apical aneurysm with a newly developed left ventricular apical thrombus on transthoracic echocardiogram (TTE). The patient had been prescribed apixaban for stroke prevention; however, he reported inconsistent medication adherence. A repeat TTE a few months later revealed the apical thrombus again despite prescribed anticoagulation. The patient remained asymptomatic. Cardiac magnetic resonance imaging (CMR) was planned for further thrombus characterization and risk assessment. This case highlights the occurrence of LVT in chronic HFrEF outside the traditional post-myocardial infarction setting and emphasizes the importance of medication adherence in preventing thrombus formation. We review current evidence regarding LVT management, emerging data supporting direct oral anticoagulants (DOACs), and factors associated with thrombus persistence and recurrence. Additionally, we discuss evolving approaches to risk stratification incorporating thrombus morphology, ventricular remodeling, artificial intelligence (AI)-assisted imaging, and genomic risk assessment. This case underscores the limitations of generalized treatment recommendations and highlights the need for individualized, risk-adapted management strategies to optimize anticoagulation duration and reduce thromboembolic complications in patients with LVT.