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Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis

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Abstract

Intracardiac thrombus most commonly develops in the left atrial appendage (LAA) and left ventricle (LV) in the setting of atrial fibrillation (AF) and post-myocardial fibrillation (MI), respectively. Current guidelines recommend that patients with post-MI LV or LAA thrombus should be treated with vitamin K antagonist (VKA). However, the use of VKA may be limited by bleeding complications, interactions with various food and drugs, and a narrow therapeutic window requiring frequent monitoring. Thus, non-VKA oral anticoagulants (NOACs) have been attempted as an off-label use for the treatment of intracardiac thrombosis in light of their favorable pharmacologic profile. Until now, therapeutic effect of NOACs on intracardiac thrombosis has not been formally studied in large randomized controlled trials. This article aims to systematically review the literature regarding efficacy and safety outcome of NOACs in the management of intracardiac thrombus. Considering the high rate of complete thrombus resolution and low rate of thromboembolic or hemorrhagic complications, preliminary evidence from case series and reports indicate that NOACs (including factor Xa inhibitors and direct thrombin inhibitors) may be a safe and effective therapeutic option for intracardiac thrombosis, particularly in cases resistant to VKA therapy.

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Abbreviations

AF:

Atrial fibrillation

HF:

Heart failure

HTN:

Hypertension

INR:

International normalized ratio

LA:

Left atrium

LAA:

Left atrial appendage

LV:

Left ventricle

MI:

Myocardial infarction

MRI:

Magnetic resonance imaging

NOAC:

Non-vitamin K antagonist oral anticoagulant

PCI:

Percutaneous coronary intervention

RV:

Right ventricle

STEMI:

ST-segment elevation myocardial infarction

TE:

Thromboembolism

TEE:

Transesophageal echocardiography

VKA:

Vitamin K antagonist

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  1. Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 930 Commonwealth Avenue #3, Boston, MA, 02215, USA

    Eiman Ghaffarpasand, Maneli D. Tehrani & Gerald Chi

  2. Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA

    Jolanta Marszalek

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  1. Eiman Ghaffarpasand
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  2. Maneli D. Tehrani
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  4. Gerald Chi
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Correspondence to Gerald Chi.

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Dr. Ghaffarpasand, Dr. Tehrani, and Dr. Marszalek declare no conflict of interest. Dr. Chi has received research Grant support paid to the Beth Israel Deaconess Medical Center from Portola Pharmaceuticals, Bayer, and Janssen Research.

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Ghaffarpasand, E., Tehrani, M.D., Marszalek, J. et al. Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis. J Thromb Thrombolysis 46, 332–338 (2018). https://doi.org/10.1007/s11239-018-1693-3

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  • DOI: https://doi.org/10.1007/s11239-018-1693-3

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