From the Research
The British guidelines for managing large left ventricular thrombus recommend anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban for at least 3-6 months, as it has been shown to be non-inferior to warfarin in terms of thrombus resolution and embolic risk reduction 1.
Key Considerations
- The use of DOACs has been increasingly recommended due to their ease of use, predictable pharmacokinetics, and lower risk of bleeding complications compared to warfarin 2, 1.
- Antiplatelet therapy with aspirin 75-100mg daily may be added to the anticoagulation regimen, although the benefits and risks of this approach need to be carefully considered on an individual basis.
- Regular echocardiographic follow-up is recommended at 1-3 month intervals to assess thrombus resolution and guide treatment decisions.
- If the thrombus resolves completely, anticoagulation may be discontinued after the recommended period, but should be continued indefinitely if the thrombus persists or if there are other indications for anticoagulation such as atrial fibrillation or severe left ventricular dysfunction.
Rationale
The approach is based on the high embolic risk of left ventricular thrombi, particularly large ones, which can lead to stroke or systemic embolism if left untreated 3, 4.
Evidence Summary
- A prospective multicentre randomized clinical trial found that apixaban was non-inferior to warfarin in treating left ventricular thrombus after acute myocardial infarction 1.
- A systematic review and meta-analysis found that DOACs were non-inferior to warfarin in terms of thrombus resolution and embolic risk reduction, with no significant difference in bleeding complications 4.
- A quality improvement project found that the use of DOACs increased from 25% to 70% over a period of 1 year, with a corresponding decrease in the time to repeat imaging and an improvement in patient outcomes 2.