In a patient with left ventricular (LV) thrombus, coronary artery disease (CAD), and a history of percutaneous coronary intervention (PCI), should we combine clopidogrel with a non-vitamin K antagonist oral anticoagulant (NOAC)?

Antithrombotic Management in LV Thrombus with CAD Post-PCI

Yes, combine clopidogrel with a NOAC in patients with LV thrombus and CAD status-post PCI, using dual antithrombotic therapy (NOAC + clopidogrel) as the default strategy after a brief initial period of triple therapy (NOAC + aspirin + clopidogrel) lasting up to 1 week. 1

Initial Periprocedural Management (First Week)

• Administer triple antithrombotic therapy (TAT) for up to 1 week consisting of aspirin (75-100 mg daily), clopidogrel (75 mg daily), and a NOAC at the recommended dose for stroke prevention 1

• Clopidogrel is the P2Y12 inhibitor of choice—avoid prasugrel or ticagrelor as part of triple therapy due to excessive bleeding risk 1

• Use low-dose aspirin (≤100 mg daily) during this brief triple therapy period 1

Transition to Dual Antithrombotic Therapy (After 1 Week)

• After 1 week, discontinue aspirin and continue dual antithrombotic therapy (DAT) with NOAC plus clopidogrel (75 mg daily) as the default strategy 1

• This approach balances the dual anticoagulation needs: the NOAC addresses the LV thrombus while clopidogrel addresses the stent thrombosis risk 1

• Triple therapy beyond 1 week should only be considered in patients with extremely high ischemic risk (prior stent thrombosis, last remaining patent coronary artery, diffuse multivessel disease in diabetics, ≥3 stents implanted, total stented length >60 mm, bifurcation with 2 stents, chronic total occlusion treatment) where ischemic risk clearly outweighs bleeding risk 1

NOAC Selection and Dosing

• Prefer NOACs over warfarin for this indication based on superior bleeding profiles in combination therapy 1

• For high bleeding risk patients (HAS-BLED ≥3), consider dabigatran 110 mg twice daily over 150 mg twice daily during concomitant antiplatelet therapy 1

• When using rivaroxaban in high bleeding risk patients, consider 15 mg once daily over 20 mg once daily for the duration of concomitant antiplatelet therapy 1

• Apixaban and rivaroxaban have been studied in this context with favorable outcomes 1, 2, 3

Duration of Therapy

• Continue dual antithrombotic therapy (NOAC + clopidogrel) for up to 12 months post-PCI 1

• After 12 months, discontinue clopidogrel and continue NOAC monotherapy for the LV thrombus 1

• The duration of NOAC therapy for LV thrombus itself typically ranges from 3-6 months, but should continue as long as the thrombus persists on imaging or indefinitely if severe LV dysfunction (ejection fraction <35%) persists 2, 4

Critical Bleeding Risk Mitigation

• Prescribe proton pump inhibitors (PPIs) routinely to all patients on combination antithrombotic therapy to reduce gastrointestinal bleeding risk 1

• Assess and correct modifiable bleeding risk factors using HAS-BLED score (hypertension control, avoid NSAIDs/alcohol, optimize renal function) 1

• Target INR 2.0-2.5 with time in therapeutic range >70% if VKA is used instead of NOAC (though NOAC is preferred) 1

Evidence Supporting NOAC Use in LV Thrombus

While current guidelines primarily address atrial fibrillation with PCI, the evidence base for NOACs in LV thrombus is growing:

• Observational studies demonstrate thrombus resolution rates of 81% with rivaroxaban, 100% with apixaban, and 88.9% with dabigatran, with median resolution times of 24-40 days 3

• A retrospective cohort of 84 patients showed no significant differences between VKA and DOAC in stroke rates (2% vs 0%), other thromboembolism (2% vs 0%), or clinically significant bleeding (10% vs 0%) over 3 years of follow-up 2

• Most patients in these studies received concomitant antiplatelet therapy (65% single agent, 38% dual therapy) without prohibitive bleeding complications 2

Common Pitfalls to Avoid

• Do not use triple therapy beyond 1 month except in the highest ischemic risk scenarios—this dramatically increases major bleeding without proportional ischemic benefit 1

• Do not combine prasugrel or ticagrelor with NOAC and aspirin as triple therapy—the bleeding risk is unacceptably high 1, 5

• Do not forget PPI prophylaxis—this is a Class I recommendation for all patients on combination antithrombotic therapy 1

• Do not continue dual antiplatelet therapy (aspirin + clopidogrel) without anticoagulation in patients with documented LV thrombus—the thromboembolic risk from LV thrombus requires anticoagulation 6, 4