What is the recommended outpatient follow‑up plan for a patient with a left‑ventricular thrombus who has been discharged on therapeutic anticoagulation?

Outpatient Follow-Up for Left Ventricular Thrombus

Patients discharged on therapeutic anticoagulation for LV thrombus require repeat imaging at 3 months to assess thrombus resolution and determine whether to continue or discontinue anticoagulation. 1, 2

Initial Anticoagulation Duration

• Continue therapeutic anticoagulation for a minimum of 3 months after LV thrombus diagnosis, regardless of the anticoagulant chosen (warfarin or DOAC). 1, 2

• The 2025 ACC/AHA guidelines explicitly state that most patients with LV thrombus warrant anticoagulation for 3 months, at which time repeat imaging should assess for residual thrombus to determine if prolonged therapy is needed. 1

Repeat Imaging Protocol

• Perform transthoracic echocardiography at 3 months to assess for thrombus resolution. 1, 2

• Additional imaging timepoints at 2 weeks, 1 month, and 6 months may be considered for high-risk patients or those with persistent wall motion abnormalities. 2

• If echocardiographic windows are inadequate or clinical suspicion remains high, cardiac MRI should be obtained as it has superior sensitivity for LV thrombus detection. 1

Decision Algorithm for Continuing Anticoagulation Beyond 3 Months

Continue anticoagulation beyond 3 months if ANY of the following are present:

• Persistent thrombus on repeat imaging at 3 months. 1, 2

• Persistent apical akinesia or dyskinesis, even if the thrombus has resolved and LVEF has improved. 1, 2

• LVEF remains <25% or shortening fraction ≤10%. 2

• History of prior systemic embolization, indicating higher ongoing thrombotic risk. 2

Discontinue anticoagulation if:

• Thrombus has completely resolved on imaging AND
• No persistent severe wall motion abnormalities AND
• LVEF has improved to >25% AND
• No prior embolic events. 2

Critical Pitfall: Premature Discontinuation

• Do not stop anticoagulation based solely on symptom improvement or LVEF recovery—imaging confirmation of thrombus resolution is mandatory. 1, 2

• The ESC case series demonstrates that thrombus recurrence occurs when anticoagulation is discontinued despite persistent wall motion abnormalities, even if initial thrombus resolved. 1, 2

• LV thrombus may form late after discharge in high-risk patients (anterior STEMI, LVEF <30%), so repeat imaging at 2-4 weeks post-discharge is warranted even if initial inpatient imaging was negative. 1, 2

Management of Concurrent DAPT

• For patients requiring DAPT after PCI with stent placement, minimize triple therapy duration to 1 month when possible, then transition to anticoagulant plus single antiplatelet agent. 2

• Consider switching from ticagrelor to clopidogrel to reduce bleeding risk when triple therapy is required. 2

• Use proton pump inhibitor for gastrointestinal bleeding prophylaxis during triple therapy. 2

• The 2025 ACC/AHA guidelines emphasize that adding anticoagulant to DAPT requires careful consideration of the patient's overall bleeding risk versus embolic event risk. 1

Anticoagulant Choice and Monitoring

• Warfarin (INR 2.0-3.0) remains the traditional standard, with INR monitoring weekly during initiation, then monthly once stable, maintaining time in therapeutic range >70%. 2

• DOACs may be considered as an alternative to warfarin, though the 2025 ACC/AHA guidelines note that evidence is limited to observational studies and small RCTs suggesting potential noninferiority for mortality, stroke, and thrombus resolution. 1, 2

• Meta-analysis data suggest DOACs are associated with reduced mortality (RR 0.66) and bleeding (RR 0.64) compared to warfarin, with nonsignificant reduction in stroke/embolic events. 3

• However, one large retrospective analysis found higher rates of stroke or systemic embolism with DOACs versus warfarin (HR 2.71), particularly beyond the recommended treatment duration. 1

High-Risk Features Requiring Extended Surveillance

• Anterior STEMI involving left anterior descending artery with LVEF <30%, especially with LV aneurysm. 1, 2

• Mobile thrombus, poor adherence to ventricular wall, or thrombus causing hemodynamic obstruction on initial imaging. 2

• Longer time to reperfusion during initial MI presentation. 1

Long-Term Thrombotic Risk

• LV thrombus should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. 4

• Embolic events can occur even after documented thrombus resolution, suggesting that anticoagulation may need to be considered for longer periods in selected cases with persistent risk factors. 4

• Observational data suggest that 80% of LV thrombi resolve by 6 months with anticoagulation, but 20% persist, necessitating continued therapy. 3