Systematic review of efficacy of direct oral anticoagulants and vitamin K antagonists in left ventricular thrombus

Emerging Elastic Micro-Nano Materials for Diagnosis and Treatment of Thrombosis

Thrombus is a blood clot that forms in a blood vessel at the point of flaking. Thrombosis is closely associated with cardiovascular diseases caused by different sources and factors. However, the current clinical methods of thrombus diagnosis and treatment still have problems with targeting, permeability, stability, and biosafety. Therefore, in recent years, based on the development of micro/nano technology, researchers have tried to develop some new strategies for the diagnosis and treatment of thrombosis. Due to the unique structural characteristics, the micro-nano materials in physiological environments show excellent transport and delivery properties such as better in vivo circulation, longer life span, better targeting ability, and controllable cellular internalization. Especially, elasticity and stiffness are inherent mechanical properties of some well-designed micro-nano materials, which can make them better adapted to the needs of thrombosis diagnosis and treatment. Herein, this review first introduces the thrombotic microenvironment to characterize the thrombus development process. Then, to fine-tune the pathological occurrence and development of thrombosis, the role of elastic micro-nano materials for thrombus diagnosis and treatment is summarized. The properties, preparation methods, and biological fate of these materials have been discussed in detail. Following, the applications of elastic micro-nano materials in biomedical imaging, drug delivery, and therapy of thrombosis are highlighted. Last, the shortcomings and future design strategies of elastic micro-nano materials in diagnosis and treatment of clinical thrombosis are discussed. This review will provide new ideas for the use of nanotechnology in clinical diagnosis and treatment of thrombus in the future.

Advancing clinical management of left ventricular thrombosis: prevention, detection and treatment modalities in the modern era

Heightened interest in left ventricular thrombus (LVT) stems from the consistent association of subsequent stroke and systemic embolism after LVT, and many aspects of its management still exist in a grey area of evidence. The current delay in intervention is likely related to a limited understanding of the disease pathophysiology, along with an underestimation of LVT by standard imaging modalities. With the rapid development of antithrombotic regimens consisting of direct oral anticoagulants (OACs), which have shown early safety and efficacy, there is a growing need to understand and accurately diagnose the LVT process in order to determine appropriate management solutions. This educational review will oversee LVT pathophysiology, current status of the guidelines-recommended echocardiographic approach and the role of multimodality imaging, as well as prevention and treatment modalities in the modern era. Meanwhile, the review proposes an algorithm for the prevention and treatment of LVT based on current guidelines and expert consensus, and highlights the need for more investigations to identify risk stratification methods for individual patients, and lastly, discusses the potential of direct OACs in the management of LVT.

Outcomes Associated With Novel Oral Anticoagulants and Warfarin in Patients With Cardiac Thrombus Following ST-Segment Elevation Myocardial Infarction

The treatment of cardiac thrombus after ST-segment elevation myocardial infarction (STEMI) is anticoagulation. There are conflicting data on the effectiveness and safety of novel oral anticoagulants (NOACs) versus warfarin. Using the national Medicare data, we identified patients with an admission diagnosis of STEMI and cardiac thrombus within 6 months after STEMI. Patients were divided into 2 groups based on initial type of anticoagulation medication (NOACs vs warfarin). The 2 main outcomes were ischemic stroke/transient ischemic attack and bleeding. Follow-up was performed through the end of 2023. Kaplan-Meier curves and Cox proportional hazard models were used. Of 881 patients prescribed anticoagulation after STEMI with subsequent cardiac thrombus, 496 patients were prescribed NOACs (56.3%) and 385 patients (43.7%) were prescribed warfarin. For ischemic stroke, the median follow-up time was 177 days (95% confidence interval [CI] 148 to 193) for warfarin and 266 days (95% CI 204 to 326) for NOACs. There was a significantly lower risk of ischemic stroke or transient ischemic attack in patients with cardiac thrombus treated with NOACs than those treated with warfarin [hazard ratio 0.73 (0.57 to 0.93)]. For bleeding, the median follow-up time was 192 days (95% CI 175 to 232) for warfarin and 277 days (95% CI 212 to 332) for NOACs. There was also a lower risk of bleeding in patients treated with NOACs than those treated with warfarin (hazard ratio 0.78, CI 0.66 to 0.92). In conclusion, patients with STEMI with cardiac thrombus had a lower risk of ischemic stroke and bleeding when treated with NOACs than when treated with warfarin. Prospective randomized studies are needed to confirm these findings and further examine the comparative effectiveness of different anticoagulant strategies.

Prediction of left ventricular thrombus after myocardial infarction: a cardiac magnetic resonance-based prospective registry

BACKGROUND

Left ventricular thrombus (LVTh) is a severe complication after ST-segment elevation myocardial infarction (STEMI).

OBJECTIVES

We aim to predict LVTh occurrence by cardiac magnetic resonance (CMR) using clinical, echocardiographic, and electrocardiographic (ECG) variables readily available at admission.

METHODS

We included 590 reperfused STEMI patients who underwent early (1-week) and/or late (6-month) CMR in our institution. Baseline clinical, echocardiographic (left ventricular ejection fraction -LVEF-) and ECG data (summatory of ST-segment elevation -sum-STE- and Q-wave and residual ST-elevation >1 mm -Q-STE-) during admission were registered. Multivariate binary logistic regression models and receiver operating characteristic curves were computed for LVTh prediction.

RESULTS

LVTh was detected by CMR in 43 (7.3 %) patients and was predicted by previous chronic coronary syndrome (CCS, HR 4.74 [1.82-12.35], p = 0.001), anterior STEMI (HR 10.93 [2.47-48.31], p = 0.002), LVEF (HR 0.96 [0.93-0.99] per %, p = 0.008), maximum sum-STE (HR 1.04 [1.01-1.07] per mm, p = 0.04), and Q-STE (HR 1.31 [1.08-1.6] per lead, p = 0.008). High-risk patients with both major (anterior STEMI and Q-STE in ≥1 leads) and 1-3 minor (CCS, maximum sum-STE >10 mm, LVEF <50%) factors showed the highest LVTh risk (19.6 % within 6 months). The model showed excellent discrimination ability (area under the curve=0.85 [0.81-0.9], p < 0.001). Simplified 4-variable (excluding sum-STE) and 3-variable (also excluding CCS) risk scores showed similar discrimination ability and were externally validated.

CONCLUSIONS

LVTh within 6 months post-STEMI can be predicted using pre-discharge clinical (anterior infarction and CCS), echocardiographic (LVEF), and ECG (sum-STE and Q-STE) data. Our results can help select patients who should undergo CMR after STEMI for LVTh detection.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Left Ventricular Thrombus After Myocardial Infarction: A Meta-Analysis

Left ventricular (LV) thrombus formation remains a post-acute myocardial infarction (AMI) complication even in the modern era of early reperfusion. The optimal anticoagulation regimen in this clinical scenario is poorly defined. The present meta-analysis sought to investigate the efficacy and safety profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for the management of LV thrombus after AMI. A systematic literature review was conducted in electronic databases to identify studies reporting efficacy and safety outcome data regarding the use of DOACs versus VKAs for patients with LV thrombus after AMI. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and random-effects meta-analyses were conducted to synthesize pooled ORs. Eight studies comprising a total of 605 patients were included. DOACs were associated with an almost twofold higher likelihood of thrombus resolution compared with VKAs (pooled OR 1.95 [1.25 to 3.04], p = 0.003, I2 = 0%), and decreased the risk of systemic embolism by 70% (pooled OR 0.30 [0.12 to 0.75]; p = 0.01, I2 = 0%). The use of DOACs was associated with a 54% lower risk of bleeding compared with VKAs (pooled OR 0.46 [0.26 to 0.84], p = 0.01, I2 = 0%). Overall, patients receiving DOACs had a 63% lower risk of reaching the composite outcome of safety and efficacy compared with patients using VKAs (pooled OR 0.37 [0.23 to 0.60], p <0.0001, I2 = 0%). In conclusion, DOACs appear to have a more favorable efficacy and safety profile compared with VKAs for the management of LV thrombus related to AMI.

Evaluation of the safety and efficacy of direct oral anticoagulants compared with vitamin-k antagonists in the treatment of left ventricular thrombosis. A systematic review and meta-analysis

BACKGROUND

Since the introduction of direct oral anticoagulants (DOACs) and their comparison with vitamin K antagonists (VKAs), conflicting results have been reported regarding the optimal treatment for left ventricular thrombosis (LVT).

OBJECTIVES

In this meta-analysis, we intend to comprehensively evaluate the safety and efficacy of these treatments.

METHODS

All clinical trials and cohorts that compared the efficacy or safety of VKAs with DOACs in the treatment of LVTs were systematically searched until April 15, 2023.

RESULTS

The results of 32 studies with a pooled sample size of 4213 patients were extracted for meta-analysis. DOACs, especially rivaroxaban and apixaban, cause faster resolution, lower mortality, and fewer complications (SSE and bleeding events) than VKAs in the management of LVTs.

CONCLUSION

Compared with VKAs, DOACs result in significantly faster (only rivaroxaban) and safer resolution of left ventricular thrombosis.

Oral anticoagulation in patients with left ventricular thrombus: a systematic review and meta-analysis

AIMS

Direct oral anticoagulants (DOACs) are increasingly used off-label to treat patients with left ventricular thrombus (LVT). We analysed available meta-data comparing DOACs and vitamin K antagonists (VKAs) for efficacy and safety.

METHODS

We conducted a systematic search and meta-analysis of observational and randomized data comparing DOACs vs. VKAs in patients with LVT. Endpoints of interest were stroke or systemic embolism, thrombus resolution, all-cause death, and a composite bleeding endpoint. Estimates were pooled using a random-effects model meta-analysis, and their robustness was investigated using sensitivity and influential analyses.

RESULTS

We identified 22 articles (18 observational studies, 4 small randomized clinical trials) reporting on a total of 3587 patients (2489 VKA vs. 1098 DOAC therapy). The pooled estimates for stroke or systemic embolism [odds ratio (OR): 0.81; 95% confidence interval (CI): 0.57, 1.15] and thrombus resolution (OR: 1.12; 95% CI: 0.86, 1.46) were comparable, and there was low heterogeneity overall across the included studies. The use of DOACs was associated with lower odds of all-cause death (OR: 0.65; 95% CI: 0.46, 0.92) and a composite bleeding endpoint (OR: 0.67; 95% CI: 0.47, 0.97). A risk of bias was evident particularly for observational reports, with some publication bias suggested in funnel plots.

CONCLUSION

In this comprehensive analysis of mainly observational data, the use of DOACs was not associated with a significant difference in stroke or systemic embolism, or thrombus resolution, compared with VKA therapy. The use of DOACs was associated with a lower rate of all-cause death and fewer bleeding events. Adequately sized randomized clinical trials are needed to confirm these findings, which could allow a wider adoption of DOACs in patients with LVT.

Left ventricular thrombus routine screening with contrast echocardiography in patients with anterior ST-elevation myocardial infarction: is it worth it?

BACKGROUND

Left ventricular (LV) thrombus has a higher incidence among patients with anterior ST-elevation myocardial infarction (STEMI) when compared to other types of acute myocardial infarction and is associated with worse prognosis. The management of LV thrombus diagnosis remains challenging. Contrast echocardiography (transthoracic echocardiography, TTE) has shown potential in improving the accuracy for its diagnosis, thereby influencing treatment strategies concerning antithrombotic/anticoagulation therapy. The aim of this study was to assess the effectiveness of contrast TTE as a routine screening method for detecting LV thrombus in the acute phase of anterior STEMI.

METHODS

A prospective, single center, randomized controlled trial was conducted among patients with anterior STEMI. The study group underwent contrast TTE, while the control group received a conventional approach. Demographical, clinical, and diagnostic data were collected. Thrombus detection rates were compared between groups.

RESULTS

A total of 68 patients were included (32 in the study group and 36 in the control group). No substantial baseline differences were observed between groups. Thrombus detection rate was 25.0% in the study group and 13.9% in the control group, however these results did not reach statistical significance (P = 0.24). The prevalence of anterior/apical aneurysm was higher in the study group (46.9% vs. 22.2%, P = 0.03).

CONCLUSIONS

Conventional TTE may be adequate for diagnosing LV thrombus in the acute phase of anterior STEMI; however, further larger-scale and multicenter studies are necessary to obtain more robust and conclusive results. Ultrasound contrast may play a significant role in the detection of anterior/apical aneurysms, which are known risk factors for the subsequent development of thrombus.

TRIAL REGISTRATION

NCT06480929 (ClinicalTrials.gov, Retrospectively registered).

Direct Oral Anticoagulants: Navigating Through Clinical Challenges

PURPOSE

Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice.

METHODS

A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date.

CONCLUSION

The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.

A China-Based Cost-Effectiveness Analysis of Novel Oral Anticoagulants versus Warfarin in Patients with Left Ventricular Thrombosis

Purpose

This study aims to conduct a comprehensive cost-effectiveness comparison between novel oral anticoagulants (NOACs) and warfarin in Chinese patients with left ventricular thrombosis (LVT). By incorporating the impact of volume-based procurement (VBP) policy for pharmaceuticals in China, this analysis intends to provide crucial insights for informed healthcare decision-making.

Patients and Methods

A Markov model was employed to simulate the disease progression of LVT over a 54-week time horizon, using weekly cycles and six mutually exclusive health states. The model incorporated transition probabilities between health states calculated based on clinical trial data and literature sources. Various cost and utility parameters were also included. Additionally, a series of sensitivity analyses were conducted to address parameter variations and associated uncertainties.

Results

The study finding suggest that from the perspective of Chinese healthcare, the majority of brand-name drug (BND) NOACs generally lack cost-effectiveness when compared to warfarin. However, when considered the VBP policy, NOACs, particularly rivaroxaban, prove to be more cost-effective than warfarin. Rivaroxaban provided an additional 0.0304 quality-adjusted life years (QALYs) per patient and reduced overall medical costs by 9095.73 CNY, resulting in an incremental cost-effectiveness ratio (ICER) of -298,786.20 CNY/QALY. Sensitivity analysis indicated a 78.4% probability of any NOACs being more cost-effective compared to warfarin. However, specifically considering NOACs under the VBP policy, the likelihood of them being more cost-effective approached 90%.

Conclusion

Taking into account Chinese pharmaceutical procurement policies, the findings highlight the superior efficacy of NOACs, especially rivaroxaban, in enhancing both the quality of life and economic benefits for Chinese LVT patients. NOACs present a more cost-effective treatment option, improving patient quality of life and healthcare cost efficiency compared to warfarin.

Reduced-Dose Apixaban in the Treatment of Left Ventricular Thrombus: A Report of 2 Cases

According to the American College of Cardiology and the American Heart Association, warfarin has historically been the standard of care anticoagulant for the treatment of left ventricular thrombus. The use of direct oral anticoagulants (DOACs) has become more prevalent, as they require less frequent laboratory monitoring, offer fixed-dose regimens, are associated with fewer drug-drug and drug-food interactions, and provide more favorable safety profiles when compared to warfarin. However, DOACs are not currently FDA-indicated in the treatment of left ventricular (LV) thrombus. Numerous recent studies have reported and evaluated the use of DOACs for treatment of LV thrombus. Recently, a prospective, open-label, multicenter study evaluated warfarin compared to DOACs for LV thrombus treatment. The AHA recently published a scientific statement regarding the management of patients at risk for and with left ventricular thrombus, which included DOACs as a reasonable alternative to warfarin. This report describes two patients treated with DOACs following LV thrombus diagnosis. The first case is a 71-year-old male admitted for cerebrovascular accident and non-ST-elevation myocardial infarction complicated by a LV thrombus. The second case is an 83-year-old female admitted for acute myocardial infarction complicated with an LV thrombus. Both patients were prescribed apixaban 2.5 mg twice daily. Neither patient has experienced LV thrombus or DOAC treatment related complications. This case series serves as evidence for reduced-dose DOACs as an alternative to warfarin in the treatment of LV thrombus.

Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment

Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.

Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta-analysis

Background and Aims

Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT.

Methods

Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio.

Results

Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group.

Conclusion

DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance.

Trial sequential analysis of efficacy and safety of direct oral anticoagulants and vitamin K antagonists against left ventricular thrombus

Meta-analysis may increase the risk of random errors. Trial sequential analysis (TSA) has been developed to adjust for these random errors. We conducted TSA on the efficacy and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in left ventricular thrombus (LVT) patients in order to estimate how many additional patients should be required to draw definite conclusions. PubMed, Scopus, and Cochrane Library databases were searched for articles directly comparing DOACs and VKAs for LVT in LV thrombus resolution, stroke, any thromboembolism, major bleeding, any bleeding, and all-cause death. TSA was conducted with a cumulative Z-curve, monitoring boundaries, and required sample size. A simulated trial was run and TSA estimated the sample sizes of trials needed to draw definite conclusions. Of 4749 articles, 25 studies were used for the analysis. TSA revealed the current sample size already demonstrated superiority of DOACs in LV thrombus resolution and stroke, and futility in any thromboembolism and all-cause death. Two other outcomes did not achieve the required sample size. The sample size of new trials needed to demonstrate the superiority of DOACs over VKAs was estimated 400 for any bleeding. Corresponding trials needed to demonstrate no significant differences could be estimated for major bleeding and any bleeding (n = 200 and n = 2000, respectively). Current results show that the sample size required to draw definite conclusions was not reached for two outcomes, and there was a risk of random error. Further randomized controlled trials with sample sizes estimated by TSA will work effectively to obtain valid conclusions.

Factors influencing left ventricular thrombus resolution and its significance on clinical outcomes

AIMS

A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes.

METHODS

We retrospectively investigated patients diagnosed with LVT with left ventricular ejection fraction (LVEF) < 50% on transthoracic echocardiography from January 2010 to July 2021 in a single tertiary centre. LVT resolution was monitored through serial follow-up transthoracic echocardiography. The primary clinical outcome was a composite of all-cause death, stroke, transient ischaemic attack, and arterial thromboembolic events. LVT recurrence was also evaluated in patients with LVT resolution.

RESULTS

There were 212 patients diagnosed with LVT (mean age, 60.5 ± 14.0 years; male, 82.5%). The mean LVEF was 33.1 ± 10.9%, and 71.7% of patients were diagnosed with ischaemic cardiomyopathy. Most patients were treated with vitamin K antagonists (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6 months was a significant factor hindering LVT resolution (hazard ratio, HR: 0.52, 95% confidence interval, CI: 0.31-0.85, P = 0.010). During a median 4.0 years of follow-up (interquartile range, IQR: 1.9 to 7.3 years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21-0.98, P = 0.045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23-7.78, P = 0.016).

CONCLUSIONS

This study suggests that LVT resolution is an important predictor for favourable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.

A prediction model for left ventricular thrombus persistence/recurrence: based on a prospective study and a retrospective study

BACKGROUND

It remains unknown whether anticoagulation for persistent left ventricular (LV) thrombus should be continued indefinitely. Identifying patients with a high risk of thrombus unresolved may be helpful to determine the optimum anticoagulation duration. This study aimed to develop a prediction model to forecast thrombus persistence or recurrence in patients with LV thrombus.

METHODS

We enrolled patients prospectively from 2020 to 2022 and retrospectively from 2013 to 2019 at the National Center of Cardiovascular Diseases of China. The two cohorts were then combined to derive predictive models of thrombus persistence/recurrence. The primary study comprised patients who received systemic oral anticoagulants and had imaging records available at the end of a 3-month follow-up period. The Lasso regression algorithm and the logistic regression were performed to select independent predictors. The calibration curve was generated and a nomogram risk prediction model was applied as a risk stratification tool.

RESULTS

A total of 172 (64 in the prospective cohort and 108 in the retrospective cohort) patients were included, with 124 patients in a training set and 48 patients in a validation set. Six predictors were incorporated into the multivariate logistic regression prediction model. The area under the receiving operating characteristic was 0.852 in the training set and 0.631 in the validation set. Patients with protuberant thrombus and higher baseline D-dimer levels had a reduced risk of persistence/recurrence (OR 0.17, 95% CI 0.03-0.69, P = 0.025; OR 0.67, 95% CI 0.43-0.91, P = 0.030, separately), whereas thicker thrombus was linked to an increased rate of persistent thrombus (OR 1.11, 95% CI 1.05-1.20, P = 0.002). Additionally, patients with diverse diagnoses or receiving different antiplatelet treatments had different rates of LV thrombus persistence/recurrence at 3 months.

CONCLUSIONS

This prediction model provides tools to forecast the occurrence of persistent/recurrent thrombus and allows the identification of characteristics associated with unresolved thrombus. To validate the model and determine the duration of anticoagulation in patients with persistent thrombus, prospective randomized trials are necessary.

Cutaneous Necrosis Over the Nose and Lower Limbs Induced by Acenocoumarol: A Case Report and Literature Review

Coumarin derivatives are the most used class of oral anticoagulants, and almost 1-2% of adults worldwide take it in the form of warfarin (WA) or acenocoumarol (AC). Cutaneous necrosis is a rare and severe complication of oral anticoagulant therapy. Most commonly, it occurs in the first 10 days, and the incidence peaks between the third and sixth day of starting treatment. Cutaneous necrosis due to AC therapy is underreported in the literature, and studies refer to this condition as "coumarin-induced skin necrosis"; however, this term is not totally accurate, as coumarin itself has no anticoagulant properties. We report a case of a 78-year-old female patient with AC-induced skin necrosis, who presented with cutaneous ecchymosis purpura over her face, arms, and lower extremities 3 hours after AC intake.

An exploratory study of effectiveness and safety of rivaroxaban in patients with left ventricular thrombus (R-DISSOLVE)

Evidence on the treatment for left ventricular (LV) thrombus is limited and mainly derives from retrospective studies. The aim of R-DISSOLVE was to explore the effectiveness and safety of rivaroxaban in patients with LV thrombus. R-DISSOLVE was a prospective, interventional, single-arm study, conducted from Oct 2020 to June 2022 at Fuwai Hospital, China. Patients with a history of LV thrombus < 3 months and with systemic anticoagulation therapy < 1 month were included. The thrombus was quantitatively confirmed by contrast-enhanced echocardiography (CE) at baseline and follow-up visits. Eligible patients were assigned to rivaroxaban (20 mg once daily or 15 mg if creatinine clearance was between 30 and 49 mL/min) and its concentration was determined by detecting anti-Xa activity. The primary efficacy outcome was the rate of LV thrombus resolution at 12 weeks. The main safety outcome was the composite of ISTH major and clinically relevant non-major bleeding. A total of 64 patients with complete CE results were analyzed for efficacy outcomes. The mean LV ejection fraction was 25.4 ± 9.0%. The dose-response curve of rivaroxaban was satisfactory based on the peak and trough plasma levels and all concentrations were in the recommended treatment range according to NOAC guidelines. The incidence rate of thrombus resolution at 6 weeks was 66.1% (41/62, 95% CI 53.0-77.7%), and of thrombus resolution or reduction was 95.2% (59/62, 95% CI 86.5-99.0%). At 12 weeks, the thrombus resolution rate was 78.1% (50/64, 95% CI 66.0-87.5%) while the rate of thrombus resolution or reduction was 95.3% (61/64, 95% CI 86.9-99.0%). The main safety outcome occurred in 4 of 75 patients (5.3%) (2 ISTH major bleeding and 2 clinically relevant non-major bleeding). In patients with LV thrombus, we reported a high thrombus resolution rate with acceptable safety by rivaroxaban, which could be a potential option for further LV thrombus treatment.Trial registration This study was registered at ClinicalTrials.gov as NCT04970381.

Impacts of Diabetes Mellitus on Cardiovascular Outcomes and Differential Effects of Direct Oral Anticoagulants in Patients with Left Ventricular Thrombus

Background

The focus of this investigation into the impact of type 2 diabetes mellitus (T2DM) on left ventricular thrombus (LVT) is (a) the differences in LVT characteristics, (b) long-term clinical outcomes, and (c) differential effects of direct oral anticoagulants (DOAC) among patients with T2DM and without diabetes.

Methods

Patients with confirmed LVT from 2009 to 2021 were included. The primary endpoints were major adverse cardiac and cerebrovascular events (MACCE), composite of cardiovascular death, ischemic stroke, and acute myocardial infarction (AMI). The secondary endpoints were all-cause death and cardiovascular death. Multivariable competing-risk regression and cumulative incidence functions (CIF) were used to evaluate the adverse consequences.

Results

In total, 1675 patients were assessed initially. Follow-up data were available for 91.1% of the participants. Median follow-up was 3.8 years. This retrospective study ultimately comprised 1068 participants, of which 429 had T2DM. Significantly higher proportions of comorbidities were observed in the T2DM group. The location, morphology, and size of LVT were similar in the two groups. Multivariable analysis suggested a higher risk of MACCE among patients with T2DM. The difference in risk between the two groups after matching and weighting was not statistically significant. Among the whole sample (n = 638) or the just the non-diabetic patients with LVT and anticoagulation (n = 382), the incidence of MACCE did not differ between DOAC treatment and warfarin treatment. In the diabetic LVT population with anticoagulation (n = 256), DOAC treatment was associated with a significantly higher risk of MACCE than was warfarin treatment.

Conclusions

The location and morphology of LVT are similar in T2DM and non-diabetic patients. A higher risk of MACCE was found among patients with diabetes.