Skip to main content
SpringerLink
Log in

The Role of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi: A Meta-Analysis and Systematic Review

  • Systematic Review
  • Published:
American Journal of Cardiovascular Drugs Aims and scope Submit manuscript

Abstract

Background

Direct oral anticoagulants (DOACs) have a well-established role in the treatment of deep vein thrombosis and pulmonary embolism and in the reduction of thromboembolism in nonvalvular atrial fibrillation. However, limited evidence supports their role in patients with left ventricular thrombi.

Methods

The PubMed, EMBASE, and Cochrane databases were searched for relevant articles published from inception to 1 August 2020. We included studies evaluating the effect of DOACs versus vitamin K antagonists (VKAs) in patients with left ventricular thrombi. The primary outcome was thrombus resolution, and the secondary outcomes were major bleeding and stroke or systemic embolization (SSE).

Results

Five retrospective observational studies were included, with a total of 857 patients. VKAs and DOACs had a similar rate of thrombus resolution (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.57–1.65; p = 0.90). Our analysis also demonstrated a similar rate of major bleeding (OR 0.62; 95% CI 0.27–1.44; p = 0.27) and SSE (OR 1.86; 95% CI 0.99–3.50; p = 0.05) between the two treatment groups.

Conclusion

In patients with left ventricular thrombi, DOACs and VKAs are associated with similar rates of thrombus resolution, major bleeding, and SSE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL, Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: screening, prevention, and treatment. JAMA Cardiol. 2018;3(7):642–9.

    Article  Google Scholar 

  2. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369:1206–14.

    Article  CAS  Google Scholar 

  3. Daher J, Da Costa A, Hilaire C, Ferreira T, Pierrard R, Guichard JB, et al. Management of left ventricular thrombi with direct oral anticoagulants: retrospective comparative study with vitamin K antagonists. Clin Drug Investig. 2020;40(4):343–53. https://doi.org/10.1007/s40261-020-00898-3.

    Article  CAS  PubMed  Google Scholar 

  4. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51. https://doi.org/10.1056/NEJMoa0905561.

    Article  CAS  PubMed  Google Scholar 

  5. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91. https://doi.org/10.1056/NEJMoa1009638.

    Article  CAS  PubMed  Google Scholar 

  6. Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, et al. Oral rivaroxaban for symptomatic venous thromboembolism the EINSTEIN investigators* the members of the writing committee. N Engl J Med. 2010;363(26):2499–510. https://doi.org/10.1056/NEJMoa1007903.

    Article  CAS  PubMed  Google Scholar 

  7. Kurogi R, Nishimura K, Nakai M, Kada A, Kamitani S, Nakagawara J, et al. Comparing intracerebral hemorrhages associated with direct oral anticoagulants or warfarin. Neurology. 2018;90(13):e1143–9. https://doi.org/10.1212/WNL.0000000000005207.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Guddeti RR, Anwar M, Walters RW, Apala D, Pajjuru V, Kousa O, et al. Treatment of left ventricular thrombus with direct oral anticoagulants: a retrospective observational study. Am J Med. 2020;133(12):1488–91. https://doi.org/10.1016/j.amjmed.2020.05.025.

    Article  CAS  PubMed  Google Scholar 

  9. Iqbal H, Straw S, Craven TP, Stirling K, Wheatcroft SB, Witte KK. Direct oral anticoagulants compared to vitamin K antagonist for the management of left ventricular thrombus. ESC Hear Fail. 2020;7(5):2032–41. https://doi.org/10.1002/ehf2.12718.

    Article  Google Scholar 

  10. Jones DA, Wright P, Alizadeh MA, Fhadil S, Rathod KS, Guttmann O, et al. The use of novel oral anti-coagulant’s (NOAC) compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction (AMI). Eur Hear J Cardiovasc Pharmacother. 2020. https://doi.org/10.1093/ehjcvp/pvaa096.

    Article  Google Scholar 

  11. Robinson AA, Trankle CR, Eubanks G, Schumann C, Thompson P, Wallace RL, et al. Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi. JAMA Cardiol. 2020;5(6):685–92. https://doi.org/10.1001/jamacardio.2020.0652.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119–77. https://doi.org/10.1093/eurheartj/ehx393.

    Article  PubMed  Google Scholar 

  13. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, et al. 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2013;61(4):e78–140. https://doi.org/10.1016/j.jacc.2012.11.019.

    Article  PubMed  Google Scholar 

  14. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160–236.

    Article  Google Scholar 

  15. Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol. 1993;22(4):1004–9. https://doi.org/10.1016/0735-1097(93)90409-t.

    Article  CAS  PubMed  Google Scholar 

  16. Abdelnabi M, Almaghraby A, Saleh Y. Will direct oral anticoagulants have a chance in prosthetic valves? Eur. Cardiol Rev. 2020;15:1–2. https://doi.org/10.15420/ecr.2019.1.3.

    Article  Google Scholar 

  17. Abdelnaby M, Almaghraby A, Abdelkarim O, Saleh Y, Hammad B, Badran H. The role of rivaroxaban in left ventricular thrombi. Anatol J Cardiol. 2019;21(1):47–50. https://doi.org/10.14744/AnatolJCardiol.2018.48313.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Fleddermann AM, Hayes CH, Magalski A, Main ML. Efficacy of direct acting oral anticoagulants in treatment of left ventricular thrombus. Am J Cardiol. 2019;124(3):367–72. https://doi.org/10.1016/j.amjcard.2019.05.009.

    Article  CAS  PubMed  Google Scholar 

  19. Mujer M, Kandola SK, Saleh Y, Herzallah K. Rarecase of biventricular thrombi complicating pulmonary embolism. BMJ Case Rep. 2019;12(5):e229698. https://doi.org/10.1136/bcr-2019-229698.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sedhom R, Abdelmaseeh P, Megaly M, Asinger R. Use of direct oral anticoagulants in the treatment of left ventricular thrombi: a systematic review. Am J Med. 2020;133(11):1266–73. https://doi.org/10.1016/j.amjmed.2020.05.012.

    Article  CAS  PubMed  Google Scholar 

  21. Tomasoni D, Sciatti E, Bonelli A, Vizzardi E, Metra M. Direct oral anticoagulants for the treatment of left ventricular thrombus—a new indication? A meta-summary of case reports. J Cardiovasc Pharmacol. 2020;75(6):530–4.

    Article  CAS  Google Scholar 

  22. He J, Ge H, Dong J-X, Zhang W, Kong L-C, Qiao Z-Q, et al. Rationale and design of a prospective multi-center randomized trial of EARLY treatment by rivaroxaban versus warfarin in ST-segment elevation MYOcardial infarction with Left Ventricular Thrombus (EARLY-MYO-LVT trial). Ann Transl Med. 2020;8(6):392. https://doi.org/10.21037/atm.2020.02.117.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S, LaBounty TM, et al. Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left ventricular thrombus. JACC Cardiovasc Imaging. 2009.

  24. Connolly SJ, Pogue J, Eikelboom J, Flaker G, Commerford P, Franzosi MG, et al. Benefit of oral anticoagulant over antiplatelet therapy in atrial fibrillation depends on the quality of international normalized ratio control achieved by centers and countries as measured by time in therapeutic range. Circulation. 2008;118(20):2029–37. https://doi.org/10.1161/CIRCULATIONAHA.107.750000.

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

No external funding was used in the preparation of this work.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Michigan State University, East Lansing, MI, USA

    Abdullah Al-abcha & Mark Mujer

  2. Department of Cardiology, Tufts University, Boston, MA, USA

    Khader Herzallah

  3. Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA

    Yehia Saleh

  4. Department of Cardiology, Alexandria University, Alexandria, Egypt

    Yehia Saleh, Ola Abdelkarim, Mahmoud Abdelnabi & Abdallah Almaghraby

  5. Department Cardiology, Michigan State University, East Lansing, MI, USA

    George S. Abela

Authors
  1. Abdullah Al-abcha
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Khader Herzallah
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yehia Saleh
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mark Mujer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ola Abdelkarim
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mahmoud Abdelnabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Abdallah Almaghraby
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. George S. Abela
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors participated in the data collection and analysis, interpretation of the study results, and the drafting, critical revision, and approval of the final version of the manuscript.

Corresponding author

Correspondence to Abdullah Al-abcha.

Ethics declarations

Conflict of interest

Abdullah Al-abcha, Khader Herzallah, Yehia Saleh, Mark Mujer, Ola Abdelkarim, Mahmoud Abdelnabi, Abdallah Almaghraby, and George S. Abela have no potential conflicts of interest that might be relevant to the contents of this systematic review.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Code availability

Not applicable.

Availability of data and material

Not applicable.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Al-abcha, A., Herzallah, K., Saleh, Y. et al. The Role of Direct Oral Anticoagulants Versus Vitamin K Antagonists in the Treatment of Left Ventricular Thrombi: A Meta-Analysis and Systematic Review. Am J Cardiovasc Drugs 21, 435–441 (2021). https://doi.org/10.1007/s40256-020-00458-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40256-020-00458-2

Search

Navigation