DOACs showed similar rates of stroke/systemic embolism (11.3% vs 17.4%, OR 0.80, p=0.5), bleeding (6.9% vs 8.4%, OR 0.81, p=0.81), and thrombus resolution as VKAs in LVT treatment.
Do direct oral anticoagulants (DOACs) reduce stroke and/or systemic embolism compared to vitamin K antagonists (VKAs) in patients with left ventricular thrombus?
DOACs appear to have similar safety and efficacy to VKAs for the treatment of left ventricular thrombus, though high-quality randomized data remain limited.
Abstract Background/Introduction Traditionally, left ventricular thrombus (LVT) has been managed with vitamin K antagonists. Following recent studies indicating the safety and efficacy of direct oral anticoagulants (DOACs) for LVT treatment, several expert committees endorsed their use in this context. Nonetheless, the underlying studies have several limitations and moreover showed conflicting results. Thus, the appropriate anticoagulation management in patients with LVT remains uncertain. Purpose Based on data from all published comparative studies, this systematic review and meta-analysis aimed to evaluate the safety and efficacy of DOACs versus VKAs in the treatment of LVT. Methods Searches of MEDLINE, Cochrane Database, Embase, conference abstracts, and ClinicalTrials.gov were conducted up to December 1, 2024. Randomized clinical trials (RCTs) and observational cohort studies comparing outcomes in patients with LVT treated with DOACs versus VKAs were considered. Three reviewers independently extracted data and assessed study quality. Risk of bias was determined using the ROBINS-I and ROB-2 tools. Random-effects models were used for comparison. The safety endpoint of interest comprised any clinically relevant bleeding. The primary efficacy outcome was the occurrence of stroke and/or systemic embolism. Additionally, thrombus resolution rate and all-cause mortality were compared. Results We included a total of 35 studies (4 RCTs and 31 observational) comprising 5049 patients (30.7% DOAC, 69.3% VKA). Among patients with LVT, no significant differences were found between DOACs and VKAs for: Stroke/systemic embolism (11.3% versus 17.4%, OR 0.80 (95% CI 0.60–1.08), p=0.5, I2=0%); bleeding events (6.9% versus 8.4%, OR 0.81 (95% CI 0.63–1.05), p=0.81, I2 0%) and thrombus resolution rate (69.2% versus 68.3%, OR 1.07 (95% CI 0.88–1.29), p=0.6 , I2 0%), as summarized in Figure 1. All-cause mortality was numerically lower in patients treated with DOACs (15.4% versus 17.9%, OR 0.93 (95% CI 0.65–1.35), p=0.02). Conclusion Based on primarily observational data, outcomes for patients with LVTs appear similar when treated with DOACs compared to VKAs. Although DOACs seem non-inferior to VKAs in LVT management, randomized trial data supporting the unrestricted prescription of DOACs in this context are lacking.
Schmal et al. (2025) studied this question. DOACs showed similar rates of stroke/systemic embolism (11.3% vs 17.4%, OR 0.80, p=0.5), bleeding (6.9% vs 8.4%, OR 0.81, p=0.81), and thrombus resolution as VKAs in LVT treatment.