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Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin
Jessica Daher1, Antoine Da Costa2,3, Christophe Hilaire1
1Division of Cardiology, Jean Monnet University, Saint-Etienne Cedex 2, Loire, France.
Insights
Direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) show similar efficacy in resolving left ventricular (LV) thrombi. VKAs remain the standard for persistent thrombi, allowing for controlled international normalized ratio (INR) levels.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Left ventricular (LV) thrombi management efficacy, particularly with direct oral anticoagulants (DOACs) in ischemic cardiomyopathy, requires further investigation.
- Vitamin K antagonists (VKAs) are a traditional treatment for LV thrombi.
Purpose of the Study:
- To compare the efficacy of DOACs and VKAs in resolving LV thrombi.
- To evaluate the rate of LV thrombus resolution after anticoagulation adjustment.
Main Methods:
- Retrospective observational study of 59 patients with LV thrombi (January 2010 - August 2019).
- Comparison of thrombus resolution rates between DOACs and VKAs.
- Switching DOAC non-responders to VKAs with a target INR of 3-4.
Main Results:
- Similar thrombus resolution rates observed: 70.6% for DOACs and 71.4% for VKAs (p=0.9).
- All patients initially on DOACs who were switched to VKAs achieved thrombus resolution.
- Embolic event rates were comparable between DOACs (11.8%) and VKAs (9.5%).
Conclusions:
- DOACs and VKAs demonstrate comparable efficacy in resolving LV thrombi.
- VKAs remain the standard of care for persistent LV thrombi due to controllable INR levels.
Background And Objectives:
The efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular (LV) thrombi remains to be determined, especially in patients with ischemic cardiomyopathy. This retrospective study sought to compare the efficacy of vitamin K antagonists (VKAs) and DOACs in patients with LV thrombi and evaluate the rate of LV thrombus resolution after adjusting anticoagulation.
Methods:
This observational retrospective study included patients admitted to our institution for LV thrombus between January 2010 and August 2019. The rate of LV thrombus resolution was compared between VKAs and DOACs. Patients without thrombus resolution with DOAC treatment were switched to VKA agents in order to obtain an international normalized ratio (INR) of 3-4.
Results:
Between January 2010 and August 2019, 59 consecutive patients with LV thrombi detected by transthoracic echocardiography were included in the study. The mean age was 62 ± 14 years and 16.9% were women. The circumstances of LV thrombus discovery were as follows: acute myocardial infarction or ischemic myocardiopathy (n = 22), stroke (n = 6), chest pain (n = 7), heart failure (n = 11), transthoracic echocardiographic evaluation (n = 11), and ventricular arrhythmias (n = 2). The proportion of patients on DOACs was 28.8% (n = 17), while that of those on VKAs was 71.2% (n = 42). Thrombus resolution was obtained in 70.6% (12/17) of patients on DOACs and in 71.4% (30/42) of those on VKAs (p = 0.9). Patients who failed to respond to DOAC treatment were treated with VKAs, and following this treatment adjustment all LV thrombi were dissolved in the DOAC group (5/5). Five embolic events (8.4% of stroke) occurred before the treatment initiation and six with anticoagulants (2/17 with DOACs [11.8%] and 4/42 with VKAs [9.5%]; p = 0.8).
Conclusions:
This retrospective observational study found a similar efficacy between DOAC and VKA agents in patients with LV thrombi (70.6% vs. 71.5%); however, when the thrombus remains, VKAs are still the standard of care as it is possible to control INR levels (3-4) with them.
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