What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Left ventricular thrombus (LVT) (n=4823). Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs). Primary outcome: LVT resolution (RR 1.04, 95% CI 0.99-1.10).

May 28, 2025Open Access

Efficacy and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonists for Left Ventricular Thrombus: A Systematic Review and Meta-Analysis

Key Result

DOACs demonstrated comparable efficacy to VKAs for left ventricular thrombus resolution (RR 1.04) and stroke prevention, while offering a significantly lower risk of bleeding events (RR 0.87).

Study Design

Type

Meta-Analysis (n=4,823)

Structured PICO

Do direct oral anticoagulants (DOACs) improve left ventricular thrombus resolution and prevent stroke or systemic embolism compared to vitamin K antagonists (VKAs) in adult patients with LVT?

Population

4,823 adult patients with left ventricular thrombus from 35 studies (5 RCTs and 30 observational) comparing direct oral anticoagulants with vitamin K antagonists, followed for 3 to 64.8 months.

Intervention

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

Comparator

Vitamin K antagonists (VKAs).

Outcome

Left ventricular thrombus (LVT) resolution.surrogate

DOACs demonstrate comparable efficacy to VKAs for left ventricular thrombus resolution and stroke prevention, while offering a superior safety profile with a significantly lower risk of bleeding.

Main Result

Relative Risk: 1.04 (95% CI 0.99–1.1)

Limitations

Most included studies were retrospective, with variable follow-up durations and clinical settings
Considerable heterogeneity across studies in terms of patient populations, antithrombotic regimens, and imaging modalities
Most studies relied on echocardiography for assessing LVT resolution, which may overestimate thrombus clearance compared to more sensitive imaging methods like cardiac MRI
Substantial variability in antiplatelet therapy use
Optimal DOAC dosing strategies and treatment durations remain unclear

Abstract

Left ventricular thrombus (LVT) is a serious complication associated with myocardial infarction and cardiomyopathy. While vitamin K antagonists (VKAs) have been the standard treatment, direct oral anticoagulants (DOACs) offer potential advantages. This meta-analysis compares the efficacy and safety of DOACs versus VKAs in patients with LVT. We conducted a systematic search of PubMed, Excerpta Medica database (Embase), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to April 2025. Studies comparing DOACs with VKAs in adult patients with LVT were included. The primary outcome was LVT resolution; secondary outcomes included stroke or systemic embolism (SSE) and bleeding events. Random-effects models were used to calculate pooled risk ratios (RRs) with 95% confidence intervals. Thirty-five studies (five RCTs and 30 observational) with 4,823 patients were included. LVT resolution was comparable between DOACs and VKAs (RR: 1.04, 95% CI: 0.99-1.10, I² = 30%). Risk of SSE showed no significant difference (RR: 0.91, 95% CI: 0.80-1.03, I² = 11%). DOACs were associated with significantly lower bleeding risk (RR: 0.87, 95% CI: 0.81-0.94, I² = 0%). Subgroup analyses by study design showed consistent findings. DOACs demonstrated comparable efficacy to VKAs for LVT resolution and stroke prevention while offering a superior safety profile with lower bleeding risk. These findings suggest DOACs may be a viable alternative to VKAs in LVT management, though large-scale randomized trials are needed to confirm these results and establish optimal dosing strategies.

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