The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction

Late presenters with ST-elevation myocardial infarction and thromboembolic complications: a treatment challenge: a case report

BACKGROUND

Late presenters with ST-elevation myocardial infarction pose a considerable challenge in the field of cardiovascular medicine. These individuals, who delay seeking medical attention after the onset of ST-elevation myocardial infarction symptoms, often face substantial difficulties in treatment. The coronavirus disease 2019 pandemic led to a significant increase in the number of late presenters. By increasing the frequency of complications such as thromboembolic events in the course of left ventricular thrombus, the pandemic necessitated the refinement of existing management strategies.

CASE PRESENTATION

In this paper, we present two White male patients of Central European (Polish) descent (50 and 64 years old) who, although reported to have had acute ST-elevation myocardial infarction, turned out to be ST-elevation myocardial infarction latecomers. In both cases, we were dealing with the presence of left ventricular thrombus and complications related to the central nervous system. On the basis of these two patients, we discuss the role of revascularization in latecomer ST-elevation myocardial infarction patients. We present the position of direct oral anticoagulants in the left ventricular thrombus treatment and show that, in limited cases of a huge thrombus, cardiac surgery is a treatment of choice.

CONCLUSIONS

As left ventricular thrombus is still relatively common in ST-elevation myocardial infarction latecomers, we present the current state of knowledge on this topic, emphasizing the need for further research in this area.

Long-term left ventricular thrombosis resolution in patients receiving vitamin k antagonists: a multicenter observational study

Optimal duration of anticoagulant therapy for left ventricular thrombous (LVT) is unclear. The aim of this study is to evaluate effectiveness and safety of vitamin K antagonists (VKAs) up to 12 months in patients with LVT. Patients diagnosed with LVT between 2011 and 2023 and treated with VKAs until LVT resolution or up to 12 months were enrolled in a retrospective cohort study. Primary outcome included on-treatment LVT resolution, secondary outcomes acute ischemic stroke, myocardial infarction, peripheral embolism, and major and clinically relevant non-major bleedings during the 12-month follow-up. Ninety patients were included. Median age was 66 years and 78.9% were male. Mean time in therapeutic range was 61% and 32.9% of patients received VKA monotherapy, with the remaining concomitant antiplatelet treatment. The 3, 6, 12 months cumulative incidences of LVT resolution were 27% (95% confidence intervals -95%CI-, 18%-36%), 47% (95%CI 36%-57%), and 70% (95% CI 60%-79%), respectively. At Cox regression model, reduced left ventricular ejection fraction (Hazard Ratio 0.48; 95%CI 0.24-0.95) and left-ventricular aneurysms (Hazard Ratio 0.44; 95%CI 0.22-0.88) were associated with reduced LVT resolution. One patient developed an acute ischemic stroke and one an acute myocardial infarction. Two patients developed a major and four a clinically relevant non-major bleeding. Incidence of LVT resolution appeared to be higher at 12 than at 3 and 6 months of follow-up, and the rates of on-treatment acute arterial and bleeding events were low. Reduced left ventricular ejection fraction and left-ventricular aneurysm appeared to be associated with a lower rates of LVT resolution.

The Efficacy and Safety of Direct Oral Anticoagulants Compared to Warfarin for Left Ventricular Thrombus Resolution

Background and Aim: Left ventricular thrombus (LVT) is a common complication of myocardial infarction (MI) and heart failure with reduced ejection fraction (HFrEF), typically managed with vitamin K antagonists (VKAs) for up to six months. However, data on direct oral anticoagulants (DOACs) for LVT treatment remain limited and conflicting. This study evaluates the effectiveness and safety of DOACs compared to warfarin for LVT resolution. Methods: We conducted a single-center retrospective cohort study of consecutive patients diagnosed with LVT from January 2010 to May 2024. The primary outcome was LVT resolution at 24 months. Safety outcomes included major bleeding and thromboembolic events. Diagnosis and follow-up were performed via echocardiography, with cardiac magnetic resonance and computed tomography as needed. Anticoagulant type, dose, duration, and concurrent antiplatelet therapy were at the treating physician's discretion. Results: Among 171 patients (82.5% male, mean age 59.8 ± 14.7 years), 99 received DOACs and 72 received warfarin. LVT resolution was higher with DOACs (66.7% vs. 50%, HR 2.0, 95% CI 1.07-3.73, p = 0.029), with a trend toward faster thrombus resolution (185 vs. 220 days, p = 0.214) though statistically not significant. DOAC use remained an independent predictor of LVT resolution, regardless of antiplatelet use. Major bleeding (2.9%), thromboembolic events (5.3%), and mortality (5.3%) were similar between groups. Conclusions: DOAC therapy was associated with higher LVT resolution rates and a comparable safety profile to warfarin. Further randomized clinical trials are warranted to validate these findings.

Left Ventricular Thrombosis in Ischemic and Non-Ischemic Cardiomyopathies: Focus on Evidence-Based Treatment

Left ventricular thrombosis (LVT) is one of the most feared complications of both ischemic and non-ischemic cardiopathy, and despite its incidence having decreased over the years (mostly due to novel reperfusion therapies in acute coronary syndromes), it is still not negligible. If transthoracic echocardiography, possibly with the adjunction of echo contrast, represents the cornerstone in LVT diagnosis, sometimes it is found to be nonconclusive and advanced cardiovascular imaging, namely cardiac magnetic resonance, needs to be performed to fully exclude intraventricular masses or to better characterize them. Vitamin K antagonists always represented the anticoagulant of choice for the treatment of LVT; however, the recent spread of direct oral anticoagulants (DOACs) pushed clinicians to adopt them also in this setting despite the absence of robust evidence in their favor. If the optimal duration of anticoagulation for the treatment of LVT in non-ischemic cardiopathy is still a matter of debate, an initial treatment of 3-6 months seems to be reasonable in the setting of ischemic cardiopathy, with possible extension according to the follow-up findings. High-quality randomized studies are strongly needed to evaluate the potential role of prophylactic anticoagulation in high-risk patients and provide conclusive evidence for the use of DOACs in LVT treatment.

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.

Long-term FXa inhibition attenuates thromboinflammation after acute myocardial infarction and stroke by platelet proteome alteration

BACKGROUND

Immediate activated factor (F)X (FXa) inhibition exerts direct antiplatelet effects in the context of arterial thrombosis but little is known about the impact of long-term therapy on platelet function in ischemic cardiovascular diseases.

OBJECTIVES

Therefore, we analyzed platelet-derived effects of long-term FXa inhibition in the setting of acute myocardial infarction (AMI) and stroke.

METHODS

We evaluated the effect of acute versus chronic FXa inhibition on thromboinflammation following AMI and stroke in mice in vivo. Mechanistically, we identified changes in platelet gene expression and proteome under chronic FXa nonvitamin K antagonist oral anticoagulant treatment and characterized its functional consequence on platelet physiology. In a prospectively recruited cohort of patients with AMI, we determined cardiovascular magnetic resonance based cardiac endpoints under FXa nonvitamin K antagonist oral anticoagulant effects on clinical endpoints in a cohort of patients with AMI.

RESULTS

Chronic but not acute FXa inhibition reduced cerebral and myocardial infarct size and improved cardiac function 24 hours after AMI in mice. Mechanistically, we identified an attenuated thromboinflammatory response with reduced neutrophil extracellular trap formation in mice and patient samples. Proteome and RNA expression analysis of FXa inhibitor treated patients revealed a reduction of key regulators within the membrane trafficking and secretion machinery hampering platelet α and dense granule release. Subsequent, thromboinflammatory neutrophil extracellular trap density in thrombi isolated from stroke and myocardial infarction patients was reduced. Patients with AMI treated with FXa inhibitors showed decreased infarct size after myocardial infarction compared to patients without anticoagulation treatment.

CONCLUSION

Long-term FXa inhibition induces antithromboinflammatory proteome signatures in platelets, improving infarct size after myocardial infarction and stroke.

Efficacy of direct oral anticoagulants vs. warfarin in left ventricular thrombus in myocardial infarction: systematic review and meta-analysis

AIMS

Current recommendations for antithrombotic strategies in left ventricular (LV) thrombus following myocardial infarction (MI) remain uncertain. This study aimed to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to warfarin in LV thrombus following MI.

METHODS

A systematic search using four databases, including PubMed, Embase, Web of Science, and Cochrane CENTRAL, was conducted from inception to 8 July 2024, without language restrictions. The inclusion criteria were studies that included patients with LV thrombus following MI and compared the efficacy or safety of DOACs and warfarin.

RESULTS

There were 11 studies (3 randomized and 8 nonrandomized) included in this meta-analysis, involving 14 927 participants. We used a random-effects model for this meta-analysis. DOACs were associated with higher thrombus resolution than warfarin, with a risk ratio (RR) of 1.07 [95% confidence interval (CI) 1.00-1.15], P  = 0.04. Similarly, DOACs were associated with a lower rate of stroke and systemic embolism, with an RR of 0.84 (95% CI 0.78-0.90), P  < 0.01. DOACs also marginally reduced the rate of major bleeding compared with warfarin, with an RR of 0.87 (95% CI 0.75-1.00), P  = 0.05.

CONCLUSIONS

DOACs were associated with higher rates of LV thrombus resolution, lower rates of stroke/systemic embolism, and marginally reduced major and bleeding events compared with warfarin in patients with LV thrombus following acute MI. Therefore, DOACs may be a reasonable alternative to warfarin in this setting.

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.

Oral anticoagulation in patients with left ventricular thrombus: a systematic review and network meta-analysis with reconstructed time-to-event data

BACKGROUND

Left ventricular thrombus (LVT) is associated with high rates of systemic embolism. Vitamin K antagonists (VKAs) are the only approved treatment for LVT. Although evidence suggests direct oral anticoagulant (DOACs) to be at least equally effective in general, the efficacy of individual DOACs remains unclear.

METHODS

A literature search was performed in EMBASE, MEDLINE and Web of Science looking for randomized controlled trials (RCTs) and non-randomized controlled studies of interventions (NRSI) comparing individual DOACs to VKAs for the treatment of LVT. Individual patient data was reconstructed and incorporated in a Bayesian network meta-analysis (NMA) and a Cox frailty regression model.

RESULTS

A total of 2545 patients across 19 studies (4 RCTs, 15 NRSI) were included. 1738 received VKAs, 581 received Rivaroxaban, 226 received Apixaban, 82 received Dabigatran and 2 received Edoxaban. LVT resolution was less likely with VKAs compared to Rivaroxaban in the time-to-event analysis (HR 0.66, 95% CI [0.49; 0.91], p = 0.01). There was no difference for other DOACs compared to VKAs. Rivaroxaban reduced ischemic stroke compared to VKAs (OR 0.18, 95% CrI [0.05; 0.49]), other DOACs did not.

CONCLUSION

In this NMA, Rivaroxaban showed faster LVT resolution and consecutively lower odds of ischemic stroke than VKAs while Apixaban and Dabigatran showed at least equal efficacy. Given the quality and size of the available studies, these differences between individual DOACs should be acknowledged as hypothesis generating only. Future adequately powered randomized controlled trials are needed to assess possible time-varying effects between individual DOACs.

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 reverse remodelling as a promising strategy for resolving left ventricular thrombus

AIMS

Recent years, several studies have suggested that abnormal baseline left ventricular (LV) function and structure are associated with left ventricular thrombus (LVT) formation. Despite this, most studies have given less attention to the potential role of left ventricular reverse remodelling (LVRR), that is, the improvement of LV function and structure, in resolving LVT. In this study, we aim to investigate the clinical characteristics, prognosis, and LVT resolution in patients with LVRR.

METHODS AND RESULTS

This is a retrospective study conducted at The First Affiliated Hospital of Dalian Medical University. Our cohort consists of patients diagnosed with LVT between 1 November 2015 and 31 May 2020. Enrolled patients were categorized into two groups: LVRR and Failure of LVRR. The primary endpoints included LVT resolution and embolic events. A total of 84 patients were included in the study, with 59 patients in the LVRR group and 25 patients in the Failure of LVRR group. In our study, patients in the LVRR group experienced higher incidence of LVT resolution and a lower risk of embolic events. Multivariate logistic analysis revealed that Failure of LVRR was the only independent negative predictor for LVT resolution and positive predictor for embolic events.

CONCLUSIONS

Patients with LVRR experience higher incidence of LVT resolution and have lower risk of embolic events, highlighting the significance of identifying and mitigating risk factors that contribute to abnormal LV function and structure in management of patients with LVT.

Evaluation of the efficacy and safety of rivaroxaban compared to warfarin in patients with left ventricular apical thrombus: a randomized clinical trial

INTRODUCTION

This research is one of the pioneering randomized clinical trials (RCTs) aimed at assessing the effectiveness and safety of rivaroxaban in treating left ventricular thrombus (LVT) in patients who have experienced acute coronary syndrome (ACS).

MATERIALS AND METHODS

This is a randomized, controlled, interventional, open-label study. The patients were randomly divided into warfarin and rivaroxaban groups. We performed transthoracic echocardiography at the start of the study and again after three months to measure the thrombus area in square millimeters. The morphology of the thrombus was categorized into mural and round, and the mobility was classified into immobile, semi-mobile and hypermobile. We also monitored for adverse events including bleeding, systemic embolic occurrences, rehospitalization, and major adverse cardiac events (MACE).

RESULTS

The study included fifty-two patients in the intention-to-treat analysis, with an equal split between the rivaroxaban and warfarin groups (26 patients each). The average follow-up duration was three months. The thrombus resolution rates in the rivaroxaban (76.9%) and warfarin (69.2%) groups, as well as the thrombus size reduction, did not show statistical significance between groups. All semi-mobile or hypermobile thrombi transformed into immobile and all of the round LVTs changed into a mural in both rivaroxaban and warfarin groups. No significant difference was observed in bleeding complications and rehospitalization between the two groups.

CONCLUSION

The trial demonstrated that rivaroxaban is as effective as warfarin in terms of thrombus resolution rate, reduction in thrombus size, bleeding risk, and rehospitalization rate. Our findings suggest that rivaroxaban is a viable alternative to warfarin for managing left ventricular thrombus.

Direct Oral Anticoagulants versus Vitamin K Antagonists for Left Ventricular Thrombus: A Meta-Analysis with Trial Sequential Analysis

BACKGROUND

Vitamin K antagonists (VKAs) are the recommended first-line treatment for left ventricular thrombus (LVT); however, direct oral anticoagulants (DOACs) have been considered an alternative therapy.

OBJECTIVES

To evaluate the efficacy and safety of DOACs compared with VKAs therapy in patients with LVT.

METHODS

PubMed, Embase, and Cochrane were systematically searched for randomized clinical trials or cohort studies that compared DOACs versus VKAs for LVT. Risk ratios (RRs) were computed for binary endpoints, with 95% confidence intervals (95% CIs). Statistical significance was defined as p value < 0.05.

RESULTS

A total of 4 randomized clinical trials and 29 cohort studies were included, with 4,450 patients assigned to either DOACs or VKAs. There was no significant difference between groups for stroke or systemic embolic (SSE) events (RR 0.84; 95% CI 0.65 to 1.07; p = 0.157), stroke (RR 0.73; 95% CI 0.48 to 1.11; p = 0.140), systemic embolic (SE) events (RR 0.69; 95% CI 0.40 to 1.17; p = 0.166), thrombus resolution (RR 1.05; 95% CI 0.99 to 1.11; p = 0.077), any bleeding (RR 0.78; 95% CI 0.60 to 1.00; p = 0.054), clinically relevant bleeding (RR 0.69; 95% CI 0.46 to 1.03; p = 0.066), minor bleeding (RR 0.73; 95% CI 0.43 to 1.23; p = 0.234), major bleeding (RR 0.87; 95% CI 0.42 to 1.80; p = 0.705), and all-cause mortality (RR 1.05; 95% CI 0.79 to 1.39; p = 0.752). Compared with VKAs, rivaroxaban significantly reduced SSE events (RR 0.35; 95% CI 0.16 to 0.91; p = 0.029) and SE events (RR 0.39; 95% CI 0.16 to 0.95; p = 0.037).

CONCLUSIONS

DOACs had a similar rate of thromboembolic and hemorrhagic events, as well as thrombus resolution, compared to VKAs in the treatment of LVTs. Rivaroxaban therapy had a significant reduction in thromboembolic events, compared to VKAs.

Multiple systemic thromboembolism secondary to acute myocardial infarction in a young patient with coronavirus disease 2019 pneumonia: A case report

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thromboembolic events. However, there are few reports on multiple thromboembolic events in young patients with COVID-19. Herein, we report a case of multiple visceral arterial embolisms secondary to acute myocardial infarction in a young patient with COVID-19. A 36-year-old male developed sudden chest pain after being diagnosed with COVID-19. Emergency coronary angiography revealed total occlusion of the right coronary artery, and the patient underwent a subsequent emergency percutaneous coronary intervention (PCI) which achieved successful recanalization. The patient was administered a loading dose and a subsequent maintenance dose of aspirin and prasugrel and a continuous intravenous infusion of unfractionated heparin at 10,000 units per day. Echocardiography detected a left ventricular apical thrombus 3 days after PCI; a loading dose of warfarin was administered and promptly reached the therapeutic range. However, the patient developed superior mesenteric artery embolism and renal infarction on the 12th day after PCI. COVID-19 was considered to play a role in the thromboembolic events observed in this patient. This case highlights the need for individualized antithrombotic regimens when managing patients with COVID-19 who develop acute myocardial infarction.

Learning objective

Reportedly, coronavirus disease 2019 (COVID-19) is associated with an increased risk of venous and arterial thromboembolic events. However, few reports have described multiple thromboembolic events in younger patients with COVID-19. This case report describes arterial thromboembolism secondary to acute myocardial infection (AMI) in a patient with COVID-19. It highlights the need for individualized antithrombotic regimens when managing patients with COVID-19 who develop AMI.

Incidence of left ventricular thrombus following STEMI in the modern era via multimodality imaging: A systematic review and meta-analysis

Background

Left ventricular thrombus (LVT) is a significant complication in STEMI. Previous studies were conducted prior to modern timely percutaneous reperfusion networks. Current expert opinion suggests incidence in the current era has decreased. We conducted a systematic review and meta-analysis to better understand the incidence and diagnosis of LVT in patients with STEMI treated with timely percutaneous techniques as assessed by multimodality imaging.

Methods

Cochrane, EMBASE, LILACS, and MEDLINE were searched over the last 10 years only including studies using contemporary techniques. The primary outcome was detection of LVT in patients via echocardiogram with or without contrast or Cardiac MRI (cMRI) following STEMI (both anterior and any territory) treated with PCI. Data was pooled across studies and statistical analysis was conducted via random effects model.

Results

31 studies were included. 18 studies included data on any territory STEMI, totaling 14,172 patients, and an incidence of 5.6% [95% CI 4.3-7.0]. 18 studies were included in analysis for anterior STEMI, totaling 7382 patients and incidence of 12.7% [95% CI 9.8-15.6]. Relative to cMRI as a gold standard, the sensitivity of non-contrast echocardiography to detect LVT was 58.2% [95% CI 46.6-69.2] with a specificity of 97.8% [95% CI 96.3-98.8].

Conclusions

Incidence of LVT in STEMI patients treated with contemporary timely percutaneous revascularization is in keeping with historical data and remains significant, suggesting this remains an ongoing issue for further investigation. Numerically, both cMRI and contrast echo detected more LVT compared to non-contrast echo in any-territory STEMI patients.

Meta-Analysis of the Safety and Efficacy of Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus

BACKGROUND

Literature on the preferred anticoagulant for treating left ventricular thrombus (LVT) is lacking. Thus, our objective was to compare the efficacy of DOACs versus warfarin in treating LVT.

METHODS

Databases were searched for RCTs and adjusted observational studies that compared DOAC versus warfarin through March 2024. The primary efficacy outcomes of interest were LVT resolution, systemic embolism, composite of stroke, and TIA. The primary safety outcomes encompassed all-cause mortality and bleeding events.

RESULTS

Our meta-analysis including 31 studies demonstrated that DOAC use was associated with higher odds of thrombus resolution (OR: 1.08, 95% CI: 0.86-1.31, p: 0.46). A statistically significant reduction in the risk of stroke/TIA was observed in the DOAC group versus the warfarin group (OR: 0.65, 95% CI: 0.48-0.89, p: 0.007). Furthermore, statistically significant reduced risks of all-cause mortality (OR: 0.68, 95% CI: 0.47-0.98, p: 0.04) and bleeding events (OR: 0.70, 95% CI: 0.55-0.89, p: 0.004) were observed with DOAC use as compared to warfarin use.

CONCLUSION

Compared to VKAs, DOACs are noninferior as the anticoagulant of choice for LVT treatment. However, further studies are warranted to confirm these findings.

Comparative effectiveness and safety of DOACs vs. VKAs in treatment of left ventricular thrombus- a meta-analysis update

BACKGROUND AND OBJECTIVE

Left ventricular thrombus (LVT) formation in patients with acute myocardial infarction (AMI) or cardiomyopathies is not uncommon. The optimal oral anticoagulation therapy for resolving LVT has been under intense debate. Vitamin K antagonists (VKAs) remain the anticoagulant of choice for this condition, according to practice guidelines. Evidence supporting the use of direct oral anticoagulants (DOACs) in the management of LVT continues to grow. We performed a systematic review and meta-analysis to compare the efficacy and safety of DOACs versus VKAs.

METHODS

A comprehensive literature search was carried out in PubMed, Cochrane Library, Web of Science, Embase, and Scopus databases in July 2023. The efficacy outcomes of this study were thrombus resolution, ischemic stroke, systemic embolism, stroke/systemic embolism, all-cause mortality, and adverse cardiovascular events. The safety outcomes were any bleeding, major bleeding, and intracranial hemorrhage. A total of twenty-seven eligible studies were included in the meta-analysis. Data were analyzed utilizing Stata software version 15.1.

RESULTS

There was no significant difference between DOACs and VKAs with regard to LVT resolution (RR = 1.00, 95% CI 0.95-1.05, P = 0.99). In the overall analysis, DOACs significantly reduced the risk of stroke (RR = 0.74, 95% CI 0.57-0.96, P = 0.021), all-cause mortality (RR = 0.70, 95% CI 0.57-0.86, P = 0.001), any bleeding (RR = 0.75, 95% CI 0.61-0.92, P = 0.006) and major bleeding (RR = 0.67, 95% CI 0.52-0.85, P = 0.001) when compared to VKAs. Meanwhile, in the sub-analysis examining randomized controlled trials (RCTs), the aforementioned outcomes no longer differed significantly between the DOACs and VKAs groups. The incidences of systemic embolism (RR = 0.81, 95% CI 0.54-1.22, P = 0.32), stroke/systemic embolism (RR = 0.85, 95% CI 0.72-1.00, P = 0.056), intracranial hemorrhage (RR = 0.59, 95% CI 0.23-1.54, P = 0.28), and adverse cardiovascular events (RR = 0.99, 95% CI 0.63-1.56, P = 0.92) were comparable between the DOACs and VKAs groups. A subgroup analysis showed that patients treated with rivaroxaban had a significantly lower risk of stroke (RR = 0.24, 95% CI 0.08-0.72, P = 0.011) than those in the VKAs group.

CONCLUSION

With non-inferior efficacy and superior safety, DOACs are promising therapeutic alternatives to VKAs in the treatment of LVT. Further robust investigations are warranted to confirm our findings.

Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus

BACKGROUND

Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR.

METHODS

Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality.

RESULTS

95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death.

CONCLUSION

The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.

Incidence and Predictors of Left Ventricular Thrombus Formation After Acute Myocardial Infarction With ST-Segment Elevation

Background and objective Our prospective study aimed to evaluate the frequency and risk factors of left ventricular thrombus (LVT) occurring after acute ST-segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (PCI). Methods Our study included 131 patients diagnosed with acute STEMI who were followed up and treated. The presence of the thrombus was determined by transthoracic echocardiography (TTE). Study patients were evaluated as cases of thrombus (+) and thrombus (-). The relationship of electrocardiographic measurements such as the number of leads with pathological Q waves, ST segment deviation score, QT dispersion, and echocardiographic measurements such as ejection fraction (EF), end-systolic and end-diastolic volumes, and wall motion score index (WMSI) with LVT was investigated. LVT risk factors were identified. Results The median age of the study patients was 59.7 ± 11.7 years, and 84.7% were male. The incidence of LVT was 17.6% (23 patients). While the anterior STEMI rate was 86.9% in the thrombus (+) group, it was 50.9% in the thrombus (-) group (p<0.001). While WMSI was 2.1 ± 0.44 in the thrombus (+) group, it was calculated as 1.40 ± 0.31 in the thrombus (-) group (p<0.001). In the thrombus (+) group, EF was found to be lower, end-systolic and end-diastolic volumes were higher, and the rate of moderate and severe mitral regurgitation and the rate of aneurysmatic segment detection were higher. LVT had a moderate correlation with WMSI (r: 0.613; p<0.001), the presence of an aneurysmatic segment (r: 0.549; p<0.001), and EF (r: -0.514; p<0.001). Presentation with anterior STEMI (odds ratio [OR]: 4.266; p<0.001), WMSI (OR: 7.971; p=0.012), the number of leads with pathological Q waves detected at discharge (OR: 3.651; p=0.009), the presence of an aneurysmatic segment (OR: 2.089, p=0.009), and EF (OR: 1.129, p=0.006) were identified as independent risk factors of the presence of LVT. The area under the curve for WMSI was found to be 0.910 (95% CI: 0.852-0.968). A WMSI cut-off of 1.56 identified LVT with 91% sensitivity and 70% specificity (Youden index: 0.617). Conclusion In the primary PCI era, LVT incidence after acute STEMI is still significant. Anterior STEMI, the number of leads with pathological Q waves detected at discharge, WMSI, aneurysm formation, and low EF are independent risk factors for LVT. Among these risk factors, the variable with the highest diagnostic power is WMSI.

Direct Oral Anticoagulation Versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials

Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKAs; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOACs) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCTs) comparing DOACs with VKAs in LV thrombus. End points were failure to resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In three eligible RCTs, 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure to resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOACs suffered fewer strokes/thromboembolic events (1/71 vs. 7/70; log odds ratio [OR], -2.02 [95% credible interval (CI95 ), -4.53 to -0.31]) and fewer bleeding events (2/71 vs. 9/70; log OR, -1.62 [CI95 , -3.43 to -0.26]), leading to fewer patients on DOACs with any adverse event versus VKAs (3/71 vs. 16/70; log OR, -1.93 [CI95 , -3.33 to -0.75]). In conclusion, pooled analysis of RCT data favors DOACs over VKAs in patients with LV thrombus in terms of both efficacy and safety.

Research on the Current Application Status of Magnesium Metal Stents in Human Luminal Cavities

The human body comprises various tubular structures that have essential functions in different bodily systems. These structures are responsible for transporting food, liquids, waste, and other substances throughout the body. However, factors such as inflammation, tumors, stones, infections, or the accumulation of substances can lead to the narrowing or blockage of these tubular structures, which can impair the normal function of the corresponding organs or tissues. To address luminal obstructions, stenting is a commonly used treatment. However, to minimize complications associated with the long-term implantation of permanent stents, there is an increasing demand for biodegradable stents (BDS). Magnesium (Mg) metal is an exceptional choice for creating BDS due to its degradability, good mechanical properties, and biocompatibility. Currently, the Magmaris® coronary stents and UNITY-BTM biliary stent have obtained Conformité Européene (CE) certification. Moreover, there are several other types of stents undergoing research and development as well as clinical trials. In this review, we discuss the required degradation cycle and the specific properties (anti-inflammatory effect, antibacterial effect, etc.) of BDS in different lumen areas based on the biocompatibility and degradability of currently available magnesium-based scaffolds. We also offer potential insights into the future development of BDS.

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.

Myocardial infarction in a 33-year-old with inflammatory bowel disease: a case report

BACKGROUND

ST elevation myocardial infarction is defined as acute myocardial injury with necrosis due to myocardial ischemia. The frequent cause is thrombotic occlusion of atherosclerotic coronary arteries. In particular situations, thromboembolism can cause myocardial infarction in patients with normal coronary arteries.

CASE PRESENTATION

We report a particular case of myocardial infarction in a young, previously healthy patient with non-atherosclerotic coronary arteries and inflammatory bowel disease. Although we performed an extensive work up, no clear pathophysiological cause could be diagnosed. Most likely, myocardial infarction was associated with a hypercoagulative state related to systemic inflammation.

CONCLUSION

The mechanisms of coagulation disturbances in the context of acute and chronic inflammation are not yet fully understood. A better understanding of cardiovascular events in patients with inflammatory bowel disease might lead to new treatment approaches of cardiovascular disease.

Efficacy and safety of direct oral anticoagulants versus vitamin K antagonists for left ventricular thrombus: an updated systematic review and meta-analysis

Aim    To perform a systematic review and meta-analysis of efficacy and safety of direct oral anticoagulants (DOAC) as compared to vitamin K antagonists (VKA) in the treatment of left ventricular (LV) thrombosis.Material and methods    A search was performed in PubMed and Google Scholar for studies that compared DOAC and VKA in the treatment of LV thrombosis with respect of thromboembolic events, hemorrhagic complications, and thrombus resolution. The effect was evaluated with the odds ratio (OR) that was computed using a fixed effects model.Results    For these systematic review and meta-analysis, 19 studies were selected, including 2 randomized and 17 cohort studies. The articles included into these systematic review and meta-analysis, were published from 2018 through 2021. In total, 2970 patients (mean age, 58.8 лет; 1879 (61.2 %) men) with LV thrombus were included into the meta-analysis. Mean follow-up duration was 17.9 months. The meta-analysis showed no significant difference between DOAC and VKA in the incidence of the study outcomes: thromboembolic events (OR, 0.86; 95 % CI: 0.67-1.10; р=0.22), hemorrhagic complications (OR, 0.77; 95 % CI: 0.55-1.07; р=0.12), thrombus resolution (OR, 0.96; 95 % CI: 0.76-1.22; р=0.77). In a subgroup analysis, rivaroxaban compared to VKA significantly (79%) reduced the risk of thromboembolic complications (OR, 0.21; 95 % CI: 0.05-0.83; р=0.03) with no significant differences in hemorrhagic events (OR, 0.60; 95 % CI: 0.21-1.71; р=0.34) or thrombus resolution (OR, 1.44; 95 % CI: 0.83-1.31; р=0.20). The apixaban treatment group had significantly more (4.88 times) cases of thrombus resolution than the VKA treatment group (OR, 4.88; 95 % CI: 1.37-17.30; р=0.01); for apixaban, data on hemorrhagic and thromboembolic complications were not available.Conclusions    The therapeutic efficacy and side effects of the DOAC treatment for LV thrombosis were similar to those of VKA with respect of thromboembolic events, hemorrhage, and thrombus resolution.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombi-Insights from a Swiss Multicenter Registry

Current guidelines recommend vitamin K antagonists (VKAs) for the treatment of a left ventricular thrombus (LVT). However, direct oral anticoagulants (DOACs) show superior safety and efficacy compared with VKAs in most thromboembolic disorders. Nevertheless, DOACs remain poorly investigated for the treatment of LVT. To describe the thrombus resolution rate and clinical efficacy of DOACs versus VKAs in patients with LVT, we analyzed consecutive patients with confirmed LVT from a multicenter echocardiography database. Echocardiograms and clinical end points were evaluated independently. The thrombus resolution rate and clinical outcomes were compared according to the underlying anticoagulation regimen. In total, 101 patients were included (17.8% women, mean age 63.3 ± 13.2 years), 50.5% had recently experienced a myocardial infarction. The mean left ventricular ejection fraction was 36.6 ± 12.2%. DOACs versus VKAs were used in 48 and 53 patients, respectively. The median follow-up was 26.6 (interquartile range 11.8;41.2) months. Among patients receiving VKAs compared with DOACs, the thrombus resolved more rapidly within the first month in those taking VKAs (p = 0.049). No differences were seen between the 2 groups with respect to major bleedings, strokes, and other thromboembolic events. In each group, LVT recurred in 3 of the subjects (a total of 6) after discontinuation of anticoagulation. In conclusion, DOACs appear to be a safe and effective alternative to VKAs for the treatment of LVTs, but the rate of thrombus dissolution within 1 month after initiation of anticoagulation appears to be higher with VKAs. A sufficiently powered randomized trial is required to definitively define the role of DOACs in the treatment of LVT.

Predictive Value of Combined Plasma D-Dimer, SCUBE1, and Right Ventricular Tei Index for the Prognosis of Elderly Patients with Acute Pulmonary Thromboembolism

Acute pulmonary thromboembolism (APTE) has become a non-negligible clinical concern due to its high mortality and complex symptoms. Early diagnosis and prognostic assessment of APTE are of great significance for the long-term benefits of patients, especially elderly patients. Elderly patients with pulmonary embolism (n = 250) who presented to our hospital from January 2018 to July 2021 were recruited into this study. In addition, 50 healthy elderly people with no history of allergies were selected as the control group. An enzyme-linked immunosorbent assay (ELISA) method was used to determine concentrations of D-dimer and signal peptide-CUB-EGF domain-containing protein-1 (SCUBE1) in their plasma. Right ventricular volume contraction time (ICT), ejection time (ET), and isovolumic relaxation time (IRT) were determined by Doppler ultrasound. Right ventricular Tei index was calculated as (ICT + IRT)/ET. High plasma D-dimer, plasma SCUBE1, and right ventricular Tei index are risk factors for poor prognosis in APTE patients after treatment. Plasma D-dimer, plasma SCUBE1, and right ventricular Tei index have predictive value for poor prognosis in APTE patients. Their combined detection (0.256*DD +0.04*SCUBE1 + 10.188*Tei) can improve the sensitivity and specificity of prediction. There is a predictive value of combined plasma D-dimer, SCUBE1, and right ventricular Tei index for the prognosis of elderly patients with APTE.

Anticoagulation for Left Ventricle Thrombus-Case Series and Literature Review for Use of Direct Oral Anticoagulants

Left ventricular thrombus is a known complication following acute myocardial infarction that can lead to systemic thromboembolism. To obviate the risk of thromboembolism, the patient needs anticoagulation in addition to dual antiplatelet therapy. However, combining antiplatelets with anticoagulants substantially increases the bleeding risk. Traditionally, vitamin K antagonists (VKAs) have been the sheet anchor for anticoagulation in this scenario. The use of direct oral anticoagulants has significantly attenuated the bleeding risk associated with anticoagulation for atrial fibrillation and venous thromboembolism. Furthermore, in patients with atrial fibrillation undergoing percutaneous coronary intervention, the use of direct oral anticoagulants (DOACs) in conjunction with antiplatelets has been found to be noninferior in reducing ischemic events while significantly attenuating the bleeding compared with VKA. After initial case reports, multiple observational and nonrandomized studies have now safely and effectively utilized direct oral anticoagulants for anticoagulation in left ventricular thrombus. Here, we report a series of two cases presenting with left ventricular thrombus following acute myocardial infarction. In this case series, we try to address the issues concerning the choice and duration of anticoagulation in the case of postinfarct left ventricular thrombus. Pending the results of large randomized control trials, the judicious use of direct oral anticoagulant is warranted when taking into consideration the ischemic and bleeding profile in an individualized approach.

Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus

In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.

Blood Coagulation Disorders in Heart Failure: From Basic Science to Clinical Perspectives

Heart failure (HF) is a clinical syndrome that is divided into 3 subtypes based on the left ventricular ejection fraction. Every subtype has specific clinical characteristics and concomitant diseases, substantially increasing risk of thromboembolic complications, such as stroke, peripheral embolism and pulmonary embolism. Despite the annual prevalence of 1% and devastating clinical consequences, thromboembolic complications are not typically recognized as the leading problem in patients with HF, representing an underappreciated clinical challenge. Although the currently available data do not support routine anticoagulation in patients with HF and sinus rhythm, initial reports suggest that such strategy might be beneficial in a subset of patients at especially high thromboembolic risk. Considering the existing evidence gap, we aimed to review the currently available data regarding coagulation disorders in acute and chronic HF based on the insight from preclinical and clinical studies, to summarize the evidence regarding anticoagulation in HF in special-case scenarios and to outline future research directions so as to establish the optimal patient-tailored strategies for antiplatelet and anticoagulant therapy in HF. In summary, we highlight the top 10 pearls in the management of patients with HF and no other specific indications for oral anticoagulation therapy. Further studies are urgently needed to shed light on the pathophysiological role of platelet activation in HF and to evaluate whether antiplatelet or antithrombotic therapy could be beneficial in patients with HF. LAY SUMMARY: Heart failure (HF) is a clinical syndrome divided into 3 subtypes on the basis of the left ventricular systolic function. Every subtype has specific clinical characteristics and concomitant diseases, substantially increasing the risk of thromboembolic complications, such as stroke, peripheral embolism and pulmonary embolism. Despite the annual prevalence of 1% and devastating clinical consequences, thromboembolic complications are not typically recognized as the leading problem in patients with HF, representing an underappreciated clinical challenge. Although the currently available data do not support routine anticoagulation in patients with HF and no atrial arrhythmia, initial reports suggest that such a strategy might be beneficial in a subset of patients at especially high risk of thrombotic complications. Considering the existing evidence gap, we aimed to review the currently available data regarding coagulation problems in stable and unstable patients with HF based on the insight from preclinical and clinical studies, to summarize the evidence regarding anticoagulation in HF in specific patient groups and to outline future research directions to establish the optimal strategies for antiplatelet and anticoagulant therapy in HF, tailored to the needs of an individual patient. In summary, we highlight the top 10 pearls in the management of patients with HF and no other specific indications for oral anticoagulation therapy.

Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants

Left ventricular thrombus (LVT) is a serious risk factor for systemic embolism development. Despite the evident danger of this condition, current guidelines describe management of patients with this potentially fatal complication very briefly. LVT can complicate myocardial infarction where its incidence is around 10%, as well as various forms of cardiomyopathies and novel coronavirus infection. According to clinical guidelines vitamin K antagonists (VKAs) should be used as treatment of choice for thrombus resolution. However, experts point out that this therapy lacks necessary evidential base and bears certain difficulties because of pharmacokinetic and pharmacodynamical properties of VKAs. These drawbacks are absent in direct oral anticoagulants (DOACs), the possibility of using which in LVT is being actively studied. As for now, published results of 3 randomised clinical trials have demonstrated similar safety and efficacy profiles of DOACs and VKAs. Similarly, the majority of retrospective cohort studies did not observe significant differences between two groups, where some of them have shown superiority of DOACs especially in terms of earlier thrombus resolution. Nevertheless, some studies have found DOACs ineffective and even potentially unsafe regarding systemic embolism. Existing data does not allow to form an unambiguous conclusion about the equivalence of DOACs and VKAs for LVT resolution. Large randomised clinical trials are needed to determine efficacy and safety of such treatment in these patients.

Interaction of Cardiovascular Nonmodifiable Risk Factors, Comorbidities and Comedications With Ischemia/Reperfusion Injury and Cardioprotection by Pharmacological Treatments and Ischemic Conditioning

Preconditioning, postconditioning, and remote conditioning of the myocardium enhance the ability of the heart to withstand a prolonged ischemia/reperfusion insult and the potential to provide novel therapeutic paradigms for cardioprotection. While many signaling pathways leading to endogenous cardioprotection have been elucidated in experimental studies over the past 30 years, no cardioprotective drug is on the market yet for that indication. One likely major reason for this failure to translate cardioprotection into patient benefit is the lack of rigorous and systematic preclinical evaluation of promising cardioprotective therapies prior to their clinical evaluation, since ischemic heart disease in humans is a complex disorder caused by or associated with cardiovascular risk factors and comorbidities. These risk factors and comorbidities induce fundamental alterations in cellular signaling cascades that affect the development of ischemia/reperfusion injury and responses to cardioprotective interventions. Moreover, some of the medications used to treat these comorbidities may impact on cardioprotection by again modifying cellular signaling pathways. The aim of this article is to review the recent evidence that cardiovascular risk factors as well as comorbidities and their medications may modify the response to cardioprotective interventions. We emphasize the critical need for taking into account the presence of cardiovascular risk factors as well as comorbidities and their concomitant medications when designing preclinical studies for the identification and validation of cardioprotective drug targets and clinical studies. This will hopefully maximize the success rate of developing rational approaches to effective cardioprotective therapies for the majority of patients with multiple comorbidities. SIGNIFICANCE STATEMENT: Ischemic heart disease is a major cause of mortality; however, there are still no cardioprotective drugs on the market. Most studies on cardioprotection have been undertaken in animal models of ischemia/reperfusion in the absence of comorbidities; however, ischemic heart disease develops with other systemic disorders (e.g., hypertension, hyperlipidemia, diabetes, atherosclerosis). Here we focus on the preclinical and clinical evidence showing how these comorbidities and their routine medications affect ischemia/reperfusion injury and interfere with cardioprotective strategies.

Effect of direct oral anticoagulants versus vitamin K antagonists or warfarin in patients with left ventricular thrombus outcomes: A systematic review and meta-analysis

INTRODUCTION

Left ventricular thrombus commonly occurs as a complication of acute anterior myocardial infarction and nonischemic cardiomyopathies with severe left ventricular systolic dysfunction. Its frequency is still high despite medical advances. Current guidelines recommend the use of vitamin k antagonists as first-line therapy, however, the off-label use of direct oral anticoagulants is becoming more frequent and attractive, given the better pharmacological and clinical profile, with the improvement of the patient's quality of life.

AIM

To provide an update on the currently existing evidence regarding the outcomes of efficacy and safety of direct oral anticoagulants (DOACs) as first-line therapy in left ventricular thrombus, in comparison to vitamin K antagonists (VKAs).

METHODS

A systematic review and meta-analysis of studies on the effects of direct oral anticoagulants versus vitamin K antagonists on left ventricular thrombi and on the results was performed.

RESULTS

Fourteen studies were included in the meta-analysis, with a total of 2498 patients (n=631 direct oral anticoagulants and n=1867 for VKAs). No significant differences were found in efficacy and safety outcomes (odds ratio (OR) 0.86; 95% confidence interval (CI), 0.55-1.33; p=0.50; I²=32%) and (OR 1.0; 95% CI, 0.78-1.30; p=0.93; I²=2%) respectively. No difference was noted in all-cause mortality (OR 0.92; 95% CI, 0.58-1.45; p=0.74; I²=0%). Thrombus resolution was observed in 288/416 in direct oral anticoagulants vs. 732/1085 patients treated with VKAs (OR 1.14; 95% CI, 0.77-1.66; p=0.50; I²=33%).

CONCLUSIONS

The findings of this meta-analysis suggest the potential utility of DOACs as a first-line strategy in patients with left ventricular thrombus.

Oral Anticoagulant Use and Appropriateness in Elderly Patients with Atrial Fibrillation in Complex Clinical Conditions: ACONVENIENCE Study

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined.

Case report: Oral anticoagulant combined with percutaneous coronary intervention for peripheral embolization of left ventricular thrombus caused by myocardial infarction in a patient with diabetes mellitus

Background

Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction (MI) in patients with diabetes. An embolic complication caused by LVT is a key clinical problem and is associated with worsened long-term survival.

Case presentation

A 45-year-old man with persistent left abdominal pain for 1 week and left leg fatigue was admitted to the emergency department. The cause of abdominal pain was embolism of the renal artery, the splenic artery, and the superior mesenteric artery caused by cardiogenic thrombosis, which further led to splenic infarction and renal infarction. It was unclear when MI occurred because the patient had no typical critical chest pain, which may have been related to diabetic complications, such as diabetic peripheral neuropathy. Diabetes plays a pivotal role in MI and LVT formation. Because coronary angiography suggested triple vessel disease, percutaneous transluminal coronary angioplasty (PTCA) was conducted, and two drug-eluting stents were placed in the left anterior descending coronary artery (LAD). Due to a lack of randomized clinical control trials, the therapy of LVT and associated embolization has been actively debated. According to the present guidelines, this patient was treated with low-molecular-weight heparin and warfarin (oral anticoagulants) for 3 months in addition to aspirin (100 mg/day) and clopidogrel (75 mg/day) for 1 year. No serious bleeding complications were noted, and a follow-up examination showed no thrombus in the left ventricle or further peripheral thrombotic events.

Conclusion

Peripheral embolization of LVT caused by MI leading to multiple organ embolization remains a rare occurrence. Diabetes plays a pivotal role in MI and LVT formation. Successful revascularization of the infarct-related coronary artery and anticoagulation therapy is important to minimize myocardial damage and prevent LVT. The present case will help clinicians recognize and manage LVT in patients with diabetes and related peripheral arterial thrombotic events with anticoagulation.

Direct oral anticoagulants versus vitamin K antagonists in the treatment of left ventricular thrombosis: a systematic review and meta-analysis

INTRODUCTION

Evidence about the use of direct oral anticoagulants (DOACs) in patients with left ventricular thrombosis (LVT) are emerging. The aim of our study was to provide a comprehensive synthesis of the available evidence concerning the clinical effects of DOACs versus vitamin K antagonists (VKAs) in LVT treatment.

EVIDENCE ACQUISITION

Systematic search of studies evaluating DOACs versus VKAs use in patients with LVT was performed on May 11^th, 2021. Data were pooled by meta-analysis using a random-effects model. Odds ratios (OR) with relative 95% confidence intervals (CI) were used as measures of effect estimates. The primary efficacy and safety endpoint were ischemic stroke and any bleeding, respectively. Secondary endpoints were LVT resolution, systemic embolism, major bleeding, hemorrhagic stroke, and all cause death.

EVIDENCE SYNTHESIS

Twenty studies were included in the meta-analysis: 1,391 patients were treated with DOACs and 1,534 with VKAs. A significant reduction in the risk of ischemic stroke (OR 0.67, 95% CI, 0.45-0.98, P=0.048, number needed to treat to benefit [NNTB] 22 [95% CI 15-43]) and any bleeding (OR 0.64, 95% CI 0.46-0.89, P=0.009, NNTB 26 [95% CI 16-80]) was observed with DOACs compared to VKAs. No statistically significant difference was observed among the two treatment arms for the secondary endpoints.

CONCLUSIONS

Compared to VKAs, DOACs are associated with a reduced risk of ischemic stroke and bleeding. In light of these findings, and the practical advantages of DOACs, additional large scale randomized controlled trials are needed to confirm the benefits of DOACs in patients with LVT.

Efficacy and Safety of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus After Acute Anterior Myocardial Infarction in Patients Who Underwent Percutaneous Coronary Intervention

AIMS

To explore treatment with Direct Oral Anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI).

BACKGROUND

Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited.

OBJECTIVES

To investigate the efficacy and safety of DOACs on the treatment of LVT post STEMI and PCI.

METHODS

This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. The primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding.

RESULTS

A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. The rate of LVT resolution was higher within 1 month in the DOACs group than warfarin (26.8% vs. 11.1%; p = 0.022) (Kaplan-Meier estimates, p = 0.002). No significant differences were found at 3 months (p = 0.246), 6 months (p = 0.201), 9 months (p = 0.171) and 12 months (p = 0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs. 2 (2.8%); p = 0.209). No death or SE occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events.

CONCLUSION

DOACs appear to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.

Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association

Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.

Rivaroxaban in heart failure patients with left ventricular thrombus: A retrospective study

Background: The role of rivaroxaban in patients with heart failure (HF) combined with left ventricular (LV) thrombus remains unknown in current guideline-directed anticoagulant therapy. The aim of this study was to investigate the impact on clinical outcomes of rivaroxaban compared to vitamin K antagonists (VKAs) in patients with HF combined with LV thrombus.

Methods: We retrospectively extracted clinical, echocardiographic and follow-up data of HF patients (all classifications) admitted at China-Japan Union Hospital of Jilin University from January 2017 to June 2021. A total of 198 patients with HF were identified with LV thrombus by echocardiography, 78 of them were managed with VKAs, 109 with rivaroxaban.

Results: The median follow-up was 17.0 months (interquartile range: 6.0–24.0 months). High rates of major cardiovascular adverse events (MACEs) were observed in both the rivaroxaban and VKAs groups (49.5% vs. 57.7%). However, rivaroxaban versus VKAs observed a decrease in MACEs (adjusted HR:0.636; 95%CI:0.418–0.970; p = 0.035) and systemic embolism (4.6% vs. 12.8%; adjusted HR:0.318; 95%CI:0.108–0.933; p = 0.037; Gray’s test p = 0.041) but was not found to have a benefit with regard to LV thrombus resolution (59.6% vs. 70.6%; adjusted HR: 1.303; 95% CI:0.898–1.890; p = 0.163; Gray’s test p = 0.073). Additionally, there was no significant between-group difference in the rate of International Society on Thrombosis and Hemostasis (ISTH) bleeding events.

Conclusion: Our data found that in populations with HF combined with LV thrombus, the overall prognosis in both the rivaroxaban and VKAs groups was catastrophic. Although rivaroxaban improved the prognosis to some extent, a considerable need remains for new treatments to improve their clinical course.

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

AIMS

Left ventricular thrombus (LVT) increases the risk of thrombotic events and mortality. Vitamin K antagonists (VKAs) used to treat LVT have several known risks, as a result of which direct oral anticoagulant (DOAC) use has recently increased. We aimed to evaluate the safety and efficacy of DOACs and VKAs in treating LVT.

METHODS AND RESULTS

We searched PubMed, Embase, Cochrane Library trials, and Web of Science databases for studies published before 19 April 2022, involving DOAC versus VKA treatment for patients with LVT. This meta-analysis comprised 21 studies (total patients, n = 3172; DOAC group, n = 888; VKA group, n = 2284). A statistically significant reduction in bleeding events was observed in patients on DOACs vs. those on VKAs (risk ratio (RR) = 0.73, P = 0.004). Patients on DOACs residing in North American and European regions and those with ischaemic heart disease (IHD) had a significantly lower risk of bleeding events than patients residing in other regions or those with a different LVT aetiology, respectively (RR = 0.78, P = 0.04; RR = 0.38, P = 0.02; and RR = 0.63, P = 0.009). A statistically significant reduction in stroke in patients on DOACs versus VKAs (RR = 0.72, P = 0.03) was observed, and patients on DOACs residing in North America and those with IHD had a significantly lower risk of stroke (RR = 0.73, P = 0.04, and RR = 0.61, P = 0.03, respectively). Compared with VKAs, DOACs are statistically associated with an increase in LVT resolution at 1 month (RR = 1.96, P = 0.008). No statistical between-group difference in all-cause mortality (RR = 0.72, P = 0.05), systemic embolism (RR = 0.87, P = 0.74), stroke or systemic embolism (RR = 0.90, P = 0.50), and LVT resolution at the end of follow-up (RR = 1.06, P = 0.13) was observed.

CONCLUSIONS

Compared with VKAs, DOACs significantly reduce the risk of bleeding events and stroke in LVT patients, but mortality was similar in both groups. The advantages are apparent not only in patients belonging to the predominantly white residential areas such as North American and European regions but also in patients with LVT due to IHD. DOACs show promising effects in treating LVT compared with VKAs.

Direct oral anticoagulants for the treatment of left ventricular thrombosis: an updated systematic review and meta-analysis

AIMS

This meta-analysis aims to compare direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in the setting of left ventricular thrombosis (LVT).

METHOD AND RESULTS

We systematically searched MEDLINE, Cochrane Library, Biomed Central and Web of Science for trials comparing DOACs versus VKAs in the setting of LVT and reporting outcome data on thrombosis resolution, stroke and bleeding. Fourteen studies were finally selected. The Mantel-Haenszel method with a random effect model was used for the pooled analysis. The primary outcome was the occurrence of LVT resolution. The secondary outcomes were the occurrence of stroke or bleeding during treatment. One thousand three hundred and thirty-two patients were included in the analysis for the primary outcome. Of these, 424 were treated with DOACs and 908 with VKAs. The pooled odds ratio (OR) for the primary outcome was 1.00 [95% confidence interval (95% CI) 0.77-1.31, I2 0.0%], reflecting equal effect in terms of thrombus resolution. Overall, 2290 patients, 608 on DOACs and 1682 on VKAs were included in the analysis of stroke occurrence, showing reduced risk of events in patients treated with DOACs (pooled OR 0.58, 95% CI 0.36-0.93; I2 0.0%) as well as for bleeding occurrence (number of patients included 2139; pooled OR 0.64, 95% CI 0.44-0.94; I2 0.0%).

CONCLUSION

Compared with VKAs, we found DOACs to have similar efficacy on thrombus resolution and favorable effects on stroke reduction and bleedings. DOACs should be considered as an alternative treatment for LVT. Large prospective randomized clinical trials are needed to confirm this exploratory finding.

Novel subgroups of patients with left ventricular thrombus and their differential effects with anticoagulation: a data-driven cluster analysis (Preprint)

UNSTRUCTURED

Ahead of Print article withdrawn by the publisher.

Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge

Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.

Large Mobile Left Ventricular Thrombi Formation in a 32-Year-Old Despite Direct Oral Anticoagulation With Dabigatran

Direct oral anticoagulant agents (DOACs) are widely used in the treatment of arterial and venous thrombi. We report the case of a 32-year-old patient who was receiving permanent DOAC therapy. Despite adequate use, 2 large left ventricular thrombi developed. Surgical thrombectomy was performed. The patient recovered well and received anticoagulation with phenprocoumon thereafter. (Level of Difficulty:Beginner.)

Pathogenetic Link of Cardiac Rupture and Left Ventricular Thrombus Following Acute Myocardial Infarction: A Joint Preclinical and Clinical Study

Background

Cardiac rupture (CR) and left ventricular thrombus (LVT) remain important complications of acute myocardial infarction (MI), and they are currently regarded as independent events. We explored the pathogenetic link between CR and LVT by investigating a murine model of MI with a high frequency of CR and in patients with acute MI.

Methods

MI was induced in mice, the onset of CR was monitored, and the hearts of mice with or without fatal CR were histologically examined. Between 2015 and 2022, from patients admitted due to acute MI, the data of patients with CR or LVT were retrospectively collected and compared to uncomplicated patients (control).

Results

A total of 75% of mice (n = 65) with MI developed CR 2–4 days after MI. A histological examination of CR hearts revealed the existence of platelet-rich intramural thrombi in the rupture tunnel, which was connected at the endocardial site to platelet-fibrin thrombi within an LVT. In CR or non-CR mouse hearts, LV blood clots often contained a portion of platelet-fibrin thrombi that adhered to the infarct wall. In non-CR hearts, sites of incomplete CR or erosion of the infarct wall were typically coated with platelet thrombi and dense inflammatory cells. Of 8,936 patients with acute MI, CR and LVT occurred in 102 (1.14%) and 130 (1.45%) patients, respectively, with three cases having both complications. CR accounted for 32.8% of in-hospital deaths. The majority of CR (95%) or LVT (63%, early LVT) occurred within 7 days. In comparison to the control or LVT-late groups, patients with CR or early LVT reported increased levels of cellular and biochemical markers for inflammation or cardiac injury.

Conclusion

CR and LVT after MI are potentially linked in their pathogenesis. LVT occurring early after MI may be triggered by a thrombo-inflammatory response following wall rupture or endocardial erosion.

Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Treatment of Left Ventricular Thrombus: An Updated Meta-Analysis of Cohort Studies and Randomized Controlled Trials

Left ventricular thrombi (LVTs) increase the risk of stroke, systemic embolism, and subsequent death. Current guidelines recommend vitamin K antagonists (VKAs) as first-line treatment for LVT. Direct oral anticoagulants (DOACs) are increasingly used as alternatives to warfarin for the treatment of LVT. However, the efficacy and safety of DOACs versus VKAs remain controversial. Thus, we conducted an updated meta-analysis of DOACs versus VKAs for LVT treatment. We systematically searched PubMed, Embase, ClinicalTrials, and Cochrane Library databases for relevant articles published before December 11, 2021. The relative risks (RRs) with 95% confidence intervals (CIs) were calculated for each study. The meta-analysis included 12 cohort studies and 3 randomized controlled trials with a total of 2334 patients. We found that DOACs had a lower risk of clinically significant bleeding than VKAs (RR = 0.6; 95% CI, 0.39 to 0.90; P = 0.01; I2 = 0%). There was no difference in LVT resolution (RR = 1.01; 95% CI, 0.93 to 1.09; P = 0.48; I2 = 0%), stroke and/or systematic embolic events (RR = 0.87; 95% CI, 0.11 to 1.55; P = 0.2; I2 = 30%), and all-cause mortality (RR = 0.9; 95% CI, 0.58 to 1.4; P = 0.65; I2 = 0%). Overall, DOACs are noninferior to warfarin in LVT treatment but have a lower risk of clinically significant bleeding. This suggests that DOACs might be better alternatives to warfarin for LVT treatment.