Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Left ventricular thrombi (n=2666). Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs). Primary outcome: Stroke (OR 0.63, 95% CI 0.42-0.96, p=0.03).

Q: What does this research mean for the field?

Direct oral anticoagulants significantly reduce the odds of stroke compared to vitamin K antagonists without an increase in bleeding in patients with left ventricular thrombi. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Faith Michael; Navneet Natt; Mohammed Shurrab

doi:10.1016/j.cjco.2021.04.007

May 6, 2021CJC OpenOpen Access

Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

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Key result

Direct oral anticoagulants significantly reduced the odds of stroke by 37% compared to vitamin K antagonists (OR 0.63) without an increase in bleeding in patients with left ventricular thrombi.

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Why the study?

DOAC use in left ventricular thrombi is considered off-label with guidelines recommending VKAs, despite increasing interest in DOACs given their safety and convenience in atrial fibrillation.

Do DOACs reduce stroke and bleeding compared to VKAs in patients with left ventricular thrombi?

Study Design

Type

Meta-Analysis (n=2,666)

Structured PICO

Do DOACs reduce stroke and bleeding compared to VKAs in patients with left ventricular thrombi?

P

Population

2,666 patients with left ventricular thrombi pooled from 18 studies (2 RCTs, 16 cohorts), followed for 3 to 36 months to compare DOACs with VKAs.

I

Intervention

Direct oral anticoagulants (DOACs) as a class, including rivaroxaban, apixaban, edoxaban, or dabigatran

C

Comparator

Vitamin K antagonists (VKAs) as a class, including warfarin, acenocoumarol, or fluindione

O

Outcome

Stroke and bleedinghard clinical

Main Result

Odds Ratio: 0.63 (95% CI 0.42–0.96)

Absolute Event Rate: 6% vs 10.8%

p-value: p=0.03

This meta-analysis suggests that DOACs may be a safe and effective off-label alternative to VKAs for left ventricular thrombi, significantly reducing the risk of stroke without increasing bleeding.

Limitations

Majority of primary studies were cohort studies prone to bias
Meta-analysis relied on pooling unadjusted event rates
Significant proportion of included studies were abstracts with limited data
Variable definitions of outcomes, including bleeding and imaging modalities for thrombus resolution
Relatively young mean age across studies limits generalizability to older patients
Lack of prospective registration for the meta-analysis
Reliance on pooling unadjusted event rates
Majority of included studies were observational cohorts with inherent biases
Eight of the 18 studies were abstracts or conference proceedings with limited information
Variability in outcome definitions (e.g., bleeding criteria) and imaging modalities
Relatively young study populations (mean age 49-63) limiting generalizability
Lack of prospective registration

Implication

Supports DOAC preference over VKAs for LV thrombi to reduce stroke without excess bleeding; extends evidence for off-label use.

Abstract

BACKGROUND: There is increasing interest in direct oral anticoagulants (DOACs), given their safety and convenience in atrial fibrillation, compared with vitamin K antagonists (VKAs). However, the use of DOACs in left ventricular (LV) thrombi is considered off-label, with current guidelines recommending VKAs. The aim of this meta-analysis was to compare the safety and efficacy of DOACs to VKAs in the management of LV thrombi. METHODS: A systematic search was conducted for studies published between January 1, 2009 and January 31, 2021 in PubMed, Embase, and CENTRAL. Included studies compared DOACs to VKAs for the treatment of LV thrombi and reported on relevant outcomes. Odds ratios (ORs) were pooled with a random-effects model. RESULTS: = 56%). CONCLUSIONS: Within the context of low-quality evidence, there was a statistically significant reduction in stroke among those treated with DOACs, without an increase in bleeding. There were no significant differences in systemic embolism, stroke or systemic embolism, mortality, or LV thrombus resolution, suggesting that DOACs may be a reasonable option for treatment of LV thrombi.

Discussion

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Cite This Study

Michael et al. (2021) conducted a meta-analysis in Left ventricular thrombi (n=2,666). Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs) was evaluated on Stroke (OR 0.63, 95% CI 0.42-0.96, p=0.03). Direct oral anticoagulants significantly reduced the odds of stroke by 37% compared to vitamin K antagonists (OR 0.63) without an increase in bleeding in patients with left ventricular thrombi.

synapsesocial.com/papers/6a6f16a7439bab0cabc2adf4 https://doi.org/10.1016/j.cjco.2021.04.007

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Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Direct Oral Anticoagulants vs Vitamin K Antagonists in Left Ventricular Thrombi: A Systematic Review and Meta-analysis

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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