One-Year Comparative Outcomes of Direct Oral Anticoagulants Versus Warfarin In Patients With Left Ventricular Thrombus And High Bleeding Risks

Management of left ventricular (LV) thrombus in patients with high bleeding risk presents a therapeutic challenge. Warfarin has been the traditional anticoagulant used for left ventricular thrombus; direct oral anticoagulants (DOACs) are increasingly used as alternatives. We decided to study whether DOAC offered any advantage over Warfarin in this high-risk group of patients. Using the TriNetX US Collaborative Network, we identified adult patients with LV thrombus and high bleeding-risk conditions (such as prior bleeds, CKD stages 3-5, Peptic ulcer disease) between 2013 and 2023. Patients were stratified into two cohorts: DOAC (n=3,762, matched n=2,208) and Warfarin (n=2,542, matched n=2,208). Outcomes assessed over one year included stroke/transient ischemic attack (TIA), cerebral infarction, mortality, acute gastrointestinal (GI) bleeding, systemic arterial embolism, intracranial hemorrhage (ICH), major bleeding, embolic events, and all-cause hospitalization. Cox regression estimated hazard ratios (HR) with 95% confidence intervals (CI); p-value <0.05 was considered significant. The mean age was 66.8 ± 14.4 for patients on DOAC and 63.9 ± 15.0 for those on warfarin. After matching, baseline characteristics were well balanced between the two groups. At one year, DOAC use was associated with significantly lower risks of mortality (24.9% vs 29.3%, HR 0.84, 95% CI 0.75-0.94, p=0.003), systemic arterial embolism (1.9% vs 3.1%, HR 0.58, 95% CI 0.39-0.88, p=0.008), intracranial hemorrhage (1.3% vs 2.3%, HR 0.56, 95% CI 0.35-0.90, p=0.016) and all-cause hospitalization was slightly lower with DOACs (72.0% vs 75.5%, HR 0.89, 95% CI 0.83-0.96, p=0.001). No significant differences were observed for Stroke/TIA, cerebral infarction, or major bleeding. In conclusion, in this large propensity-matched cohort of patients with LV thrombus and high bleeding risk, use of DOACs demonstrated superior safety and effectiveness compared to warfarin, with reduced mortality, major bleeding, and thromboembolic complications. These findings support the use of DOACs in this high-risk population, though prospective randomized trials are warranted.