From the Guidelines
For patients with severe heart failure (EF 5-10%) who develop biventricular thrombi while on heparin infusion and subsequently suffer a stroke, transitioning to a direct oral anticoagulant (DOAC) such as apixaban 5mg twice daily or rivaroxaban 20mg daily is recommended once the patient is stabilized. This approach is based on the most recent guidelines for anticoagulation in patients with atrial fibrillation and heart failure, as outlined in the 2024 ESC guidelines for the management of atrial fibrillation 1. The selection of an anticoagulant agent should be individualized, considering the patient's risk factors for thromboembolism and bleeding, as well as their renal function and other comorbidities.
Anticoagulation Strategy
The patient's development of biventricular thrombi despite being on heparin infusion indicates a high risk of thromboembolic events, and thus, a more effective anticoagulation strategy is warranted. The use of DOACs has been shown to be effective in preventing stroke and systemic embolism in patients with atrial fibrillation, with a more favorable bleeding risk profile compared to warfarin 1.
Guideline-Directed Medical Therapy
In addition to optimizing anticoagulation, it is crucial to maximize advanced heart failure therapies, including guideline-directed medical therapy with:
- Beta-blockers (e.g., carvedilol 3.125mg twice daily, titrated as tolerated) 1
- ACE inhibitors/ARBs/ARNI (starting with low doses and titrating up) 1
- Aldosterone antagonists (e.g., spironolactone 25mg daily) for patients with NYHA class II–IV and LVEF ≤35% 1
Advanced Therapies
For patients with severely reduced EF, evaluation for advanced therapies including left ventricular assist device (LVAD) or heart transplantation should be expedited. Cardiac resynchronization therapy (CRT) should be considered if QRS duration is prolonged.
Neurological Evaluation
The stroke requires neurological evaluation for potential rehabilitation needs, emphasizing the importance of a multidisciplinary approach in managing these complex patients.
This comprehensive strategy addresses both the thromboembolic complications and the underlying severe cardiac dysfunction, aiming to improve morbidity, mortality, and quality of life for the patient.
From the Research
Treatment Options for Patients with HF (EF 5-10) and Biventricular Thrombi
- For patients with heart failure and biventricular thrombi, anticoagulation therapy is crucial to prevent further thromboembolic events 2.
- The use of novel oral anticoagulants (NOACs) has been shown to be effective in reducing stroke risk in patients with atrial fibrillation and heart failure 2, 3.
- In patients with heart failure and reduced ejection fraction, the use of warfarin has been disappointing, with an increased risk of bleeding compared to aspirin 2.
- The COMMANDER-HF trial is currently ongoing to investigate the use of NOACs in heart failure patients with reduced ejection fraction in sinus rhythm 2.
Management of Biventricular Thrombi
- The management of biventricular thrombi in patients with heart failure is complex and requires a multidisciplinary approach 4.
- Anticoagulation therapy is essential to prevent further thromboembolic events, and the use of NOACs may be considered in certain patients 2, 3.
- The risk of stroke and systemic embolism is high in patients with heart failure and biventricular thrombi, and individualized risk stratification is necessary to guide treatment decisions 5.
Stroke Prevention in Patients with HF and Biventricular Thrombi
- Stroke prevention is critical in patients with heart failure and biventricular thrombi, and anticoagulation therapy is essential to reduce this risk 2, 5.
- The CHA2DS2-VASc score may be useful in predicting stroke risk in patients with heart failure, regardless of the presence of atrial fibrillation 5.
- Current guidelines recommend the use of non-vitamin K antagonist anticoagulants over warfarin in patients with heart failure and atrial fibrillation 5.