Key result
Direct oral anticoagulants demonstrated similar efficacy to warfarin for left ventricular thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09).
Why the study?
With the addition of the RIVAWAR trial, an updated systematic review and meta-analysis was needed to assess the efficacy and safety of DOACs compared with warfarin in patients with LV thrombus.
Do direct oral anticoagulants (DOACs) improve thrombus resolution at 3 months compared to warfarin in patients with a left ventricular thrombus?
Meta-Analysis (n=554)
Do direct oral anticoagulants (DOACs) improve thrombus resolution at 3 months compared to warfarin in patients with a left ventricular thrombus?
DOACs demonstrate similar efficacy and safety to warfarin for the management of left ventricular thrombus, supporting their use as a convenient alternative.
Answers are grounded in this paper and cite their sources.
DOACs match warfarin for LV thrombus resolution and safety outcomes; reinforces RCT evidence supporting convenient alternative use.
BACKGROUND: Left ventricular (LV) thrombus is a complication of myocardial infarction and dilated cardiomyopathy and is associated with a high thromboembolic risk. Although warfarin has traditionally been used, direct oral anticoagulants (DOACs) offer a more convenient alternative. With the addition of the RIVAWAR trial, we conducted an updated systematic review and meta-analysis to assess the efficacy and safety of DOACs compared with warfarin in patients with LV thrombus. METHODS: A systematic search of electronic databases (PubMed, EMBASE, Cochrane and clinicaltrials.gov) from inception to April 2025 identified randomised clinical trials (RCTs) comparing DOACs with warfarin for the treatment of LV thrombus. The main outcome of interest was thrombus resolution at 3 months. Risk ratios (RRs) with 95% CIs were calculated using random-effects models. RESULTS: Seven RCTs comprising 554 patients were included. Non-contrast transthoracic echocardiography was used for LV thrombus assessment in all RCTs. There was no difference between DOACs and warfarin in thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09), major adverse cardiovascular events (RR 0.50; 95% CI 0.16 to 1.54), all-cause mortality (RR 0.92; 95% CI 0.36 to 2.31), stroke/systemic embolism (RR 0.76; 95% CI 0.12 to 4.68), rehospitalisation (RR 1.36; 95% CI 0.47 to 3.94) or major bleeding (RR 0.54; 95% CI 0.20 to 1.48). Subgroup and sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: DOACs demonstrated similar efficacy and safety to warfarin for LV thrombus management in this meta-analysis, supporting their use for the treatment of LV thrombus. However, large-scale RCTs with longer follow-up periods and using diagnostic modalities with higher sensitivity and specificity for detecting LV thrombus resolution are warranted to confirm these findings and clarify long-term outcomes. PROSPERO REGISTRATION NUMBER: CRD420251023513.
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Costa et al. (2025) conducted a meta-analysis in Left ventricular (LV) thrombus (n=554). Direct oral anticoagulants (DOACs) vs. Warfarin was evaluated on Thrombus resolution at 3 months (RR 1.02, 95% CI 0.95 to 1.09). Direct oral anticoagulants demonstrated similar efficacy to warfarin for left ventricular thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09).
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