What are the management options for a patient with left ventricular (LV) thrombosis who is on Direct Oral Anticoagulant (DOAC) therapy?

From the Guidelines

For patients with left ventricular (LV) thrombosis, anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, or dabigatran is recommended for at least 3 months, as it has been shown to be effective in reducing the risk of stroke or systemic embolism 1. The use of DOACs in this context is supported by a pooled meta-analysis of studies, which found that anticoagulation with vitamin K antagonists (VKAs) reduced the risk of stroke by 86% and resulted in resolution of LV thrombus in 68% of patients 1. Although the evidence for DOACs is not as extensive as for VKAs, a single-center retrospective study found that anticoagulation with a DOAC resulted in resolution of the thrombus in 86% of patients on follow-up echocardiography 1. Some key points to consider when using DOACs for LV thrombosis include:

• Dose adjustments may be necessary based on renal function, weight, and bleeding risk 1
• Treatment duration depends on thrombus resolution (confirmed by follow-up imaging) and underlying cause 1
• Regular follow-up echocardiography is recommended to assess thrombus resolution, typically at 1-3 month intervals 1
• Patients should be counseled about bleeding risks, medication adherence importance, and the need to inform healthcare providers about their anticoagulation status before procedures 1 It is also important to note that the risk of stroke or systemic embolism in the presence of LV thrombus is reduced by use of systemic anticoagulation, and that the risk of embolism is reduced after 3 months 1. The detection of LV thrombus is an important determinant of stroke type and appropriate therapy, and can be done using standard transthoracic echocardiography, contrast echocardiography with the use of a microbubble contrast agent, or cardiac MRI, with cardiac MRI being the most sensitive modality 1.

From the Research

LV Thrombosis and DOAC Treatment

• The use of Direct Oral Anticoagulants (DOACs) in the treatment of Left Ventricular Thrombus (LVT) has been studied in several research papers 2, 3, 4, 5, 6.
• A systematic review of current literature found that DOACs are being increasingly used for the management of LVT, despite the lack of randomized trials in support of it or knowledge about their efficacy 2.
• The study found that the most common risk factors for LVT formation were male gender, ischemic heart disease, and low ejection fraction, and that the thrombus resolution success rate was 81%, 100%, and 88.9% for rivaroxaban, apixaban, and dabigatran, respectively 2.
• Another study reported two cases of patients treated with reduced-dose apixaban for LVT, with no complications or adverse events 3.
• A single-center study compared the use of warfarin and DOACs in patients with LVT and found that there was no statistical difference in stroke risk or rate of thrombus resolution between the two groups 4.
• A systematic review and meta-analysis of observational and randomized data found that the use of DOACs was associated with lower odds of all-cause death and a composite bleeding endpoint compared to vitamin K antagonists (VKAs) 5.
• A network meta-analysis found that rivaroxaban showed faster LVT resolution and lower odds of ischemic stroke than VKAs, while apixaban and dabigatran showed at least equal efficacy 6.

Efficacy and Safety of DOACs

• The efficacy and safety of DOACs in the treatment of LVT have been evaluated in several studies, with varying results 2, 3, 4, 5, 6.
• A study found that the use of DOACs was a reasonable alternative to vitamin-K antagonists in the management of LVT, with a thrombus resolution success rate of 81% for rivaroxaban, 100% for apixaban, and 88.9% for dabigatran 2.
• Another study reported that the use of reduced-dose apixaban was a viable option for the treatment of LVT, with no complications or adverse events 3.
• A meta-analysis found that the use of DOACs was associated with lower odds of all-cause death and a composite bleeding endpoint compared to VKAs 5.

Comparison of DOACs

• The comparison of different DOACs in the treatment of LVT has been evaluated in several studies, with varying results 2, 5, 6.
• A study found that rivaroxaban, apixaban, and dabigatran had thrombus resolution success rates of 81%, 100%, and 88.9%, respectively 2.
• A network meta-analysis found that rivaroxaban showed faster LVT resolution and lower odds of ischemic stroke than VKAs, while apixaban and dabigatran showed at least equal efficacy 6.
• A meta-analysis found that the use of DOACs was associated with lower odds of all-cause death and a composite bleeding endpoint compared to VKAs, with no significant difference between individual DOACs 5.