“Real-World Effectiveness and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonists in Left Ventricular Thrombus: A Systematic Review and Meta-Analysis of Cohort Studies”

Left ventricular thrombus (LVT) is associated with systemic embolism, while anticoagulation carries a bleeding risk. Although vitamin K antagonists (VKAs) have been the standard treatment, direct oral anticoagulants (DOACs) are increasingly used despite limited randomized evidence. This systematic review and meta-analysis compared the efficacy and safety of DOACs versus VKAs in adults with confirmed LVT. PubMed, Scopus, Web of Science, and the Cochrane Library were searched from inception to 29 November 2025. Observational cohort studies comparing DOACs versus VKAs were included. Primary outcomes were LVT resolution and systemic thromboembolism. Secondary outcomes included major bleeding, clinically significant non-major bleeding, and all-cause mortality. Random-effects meta-analyses used odds ratios (ORs) with 95% confidence intervals (CIs). Risk of bias was assessed using the ROBINS-I tool, and sensitivity analyses addressed outcomes dominated by large studies. Seventeen studies involving 46,832 patients (24,148 DOAC; 22,684 warfarin) were included. DOACs were associated with greater LVT resolution (OR 1.29, 95% CI 1.03–1.63; I² = 5%) and a lower risk of major bleeding (OR 0.58, 95% CI 0.34–0.99; I² = 11%) than VKAs. Although pooled analysis suggested reduced systemic thromboembolism with DOACs (OR 0.76, 95% CI 0.69–0.84), this association lost statistical significance after sensitivity analysis excluding a dominant study. No significant differences emerged for clinically significant non-major bleeding, any bleeding and all-cause mortality. In observational studies, DOACs were associated with improved thrombus resolution and reduced major bleeding versus VKAs. However, evidence for reduced systemic thromboembolism was not robust in sensitivity analyses. Randomized trials are needed to establish definitive treatment recommendations.