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Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after
Zhongfan Zhang1, Daoyuan Si1, Qian Zhang1
1Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China.
Insights
Rivaroxaban triple therapy demonstrated similar and faster resolution of left ventricular thrombus (LVT) in ST-Elevation myocardial infarction (STEMI) patients compared to Vitamin K Antagonists (VKA). This approach may offer improved clinical benefits, warranting further investigation.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Pharmacology
Background:
- Left ventricular thrombus (LVT) is a complication of ST-Elevation Myocardial Infarction (STEMI), associated with adverse outcomes.
- Conventional treatment involves Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT).
- Limited contemporary data exists on triple therapy with rivaroxaban for LVT post-STEMI.
Purpose of the Study:
- To compare the efficacy of rivaroxaban plus DAPT versus VKA plus DAPT in patients with LVT following STEMI.
- To evaluate LVT resolution rates, net clinical adverse events (NACE), and bleeding events.
Main Methods:
- Retrospective cohort study of 1335 STEMI patients undergoing primary percutaneous coronary intervention (PCI).
- Comparison of LVT resolution, NACE, and bleeding between rivaroxaban plus DAPT and VKA plus DAPT groups.
- Analysis included log-rank tests and adjusted hazard ratios for efficacy and safety outcomes.
Main Results:
- Of 1335 STEMI patients, 77 (5.7%) developed LVT.
- Rivaroxaban plus DAPT showed similar LVT resolution rates compared to VKA plus DAPT (Adjusted HR 1.70; p=0.104), with significantly quicker resolution at 6, 12, and 18 months.
- The rivaroxaban group had fewer NACE (Adjusted HR 0.23; p=0.001) and similar bleeding risks (Adjusted HR 0.48; p=0.444).
Conclusions:
- Triple therapy with rivaroxaban appears to offer similar and faster LVT resolution post-STEMI compared to VKA.
- Rivaroxaban therapy may be associated with better clinical benefits and comparable safety.
- Larger randomized controlled trials are necessary to confirm these findings.
Background:
Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking.
Methods:
We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events.
Results:
In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001].
Conclusion:
In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.
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