Advancements in stroke prevention for left ventricular thrombus: A global survey in the DOAC era and a call for updated guidelines

Left ventricular thrombus (LVT) is a clinically significant source of cardioembolic stroke, particularly in patients with myocardial infarction and reduced left ventricular ejection fraction. Optimal anticoagulation strategies remain debated in the era of direct oral anticoagulants (DOACs). This review summarizes current evidence comparing DOACs and vitamin K antagonists (VKAs), including data from observational studies, randomized controlled trials, and meta-analyses. While early studies raised concerns regarding higher embolic risk with DOACs, more recent evidence suggests comparable thrombus resolution with a trend toward reduced bleeding and possibly lower mortality. In addition, we present findings from a global survey of 40 clinicians assessing real-world practice patterns. The results demonstrate substantial variability in anticoagulant selection, with 60% favoring DOACs and 40% preferring warfarin. Nearly all respondents (98%) agreed on the need for updated evidence-based guidelines. Overall, emerging data and contemporary clinical practice patterns support the growing role of DOACs as a viable alternative to VKAs in selected patients with LVT. Further large-scale randomized trials are needed to better define optimal treatment strategies and inform future guidelines.