From the Guidelines
Apical thrombus should be treated with anticoagulation therapy, initially with intravenous unfractionated heparin or low-molecular-weight heparin, and subsequently with oral anticoagulants for at least 3-6 months, as recommended by the European Society of Cardiology 1.
Treatment Overview
The goal of treatment is to prevent thrombus growth and embolization, which could lead to stroke or systemic embolism.
- Anticoagulation therapy is the mainstay of treatment, with the aim of reducing the risk of thromboembolic events.
- The choice of anticoagulant and duration of treatment depend on the individual patient's risk factors and clinical presentation.
Anticoagulation Therapy
- Initial treatment with intravenous unfractionated heparin or low-molecular-weight heparin is recommended, followed by oral anticoagulants for at least 3-6 months 1.
- Direct oral anticoagulants (DOACs) like apixaban or rivaroxaban may be considered in certain cases, although their use in apical thrombus is not well established.
Monitoring and Follow-up
- Patients should undergo follow-up echocardiography at 1-3 months to assess for thrombus resolution.
- The underlying cause of the thrombus, such as myocardial infarction or cardiomyopathy, must also be addressed.
- Patients should be monitored for bleeding complications while on anticoagulation therapy and educated about medication adherence, bleeding signs, and the importance of regular follow-up.
Surgical Removal
- If the thrombus persists despite adequate anticoagulation, or if the patient has contraindications to anticoagulation, surgical removal may be considered.
- However, this is typically reserved for cases where the thrombus is large or mobile, and the patient is at high risk of thromboembolic events.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Apical Thrombus Treatment
- The treatment of apical thrombus often involves anticoagulation therapy, with vitamin K antagonists (VKAs) being the traditional first-line therapy 2.
- However, direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, and dabigatran have shown promise in reducing the risk of embolic events and demonstrating rapid reduction in size or full resolution of an LV thrombus 2, 3.
- A study comparing apixaban and warfarin in patients with left ventricular thrombus found that apixaban was non-inferior to warfarin with a 20% non-inferiority margin 4.
Direct Oral Anticoagulants (DOACs)
- DOACs are advantageous in comparison to VKAs and are used to treat non-valvular atrial fibrillation, pulmonary embolisms, and prevent recurrent deep vein thrombosis in adults 5.
- The use of DOACs in the treatment of left ventricular thrombus is a reasonable alternative to vitamin-K antagonists, with a thrombus resolution success rate of 81% for rivaroxaban, 100% for apixaban, and 88.9% for dabigatran 3.
- DOACs have also been used in patients with disseminated intravascular coagulation (DIC), although their indication for preventing DIC in high-risk patients may be limited 6.
Clinical Trials and Guidelines
- Large, randomized research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed to lead to a change in standard clinical practice that could benefit patients 2.
- Current guidelines recommend anticoagulation with a vitamin K antagonist to treat left ventricular thrombus after myocardial infarction (MI), but data on the use of DOACs in this setting are limited 4.
- The American Family Physician recommends direct oral anticoagulants as first-line agents for eligible patients for treating venous thromboembolism and preventing stroke in those with nonvalvular atrial fibrillation 5.