Assessing the Efficacy of Direct Oral Anticoagulants in Nonbacterial Thrombotic Endocarditis Patients

Nonbacterial thrombotic endocarditis is a rare condition associated with hypercoagulable states, including malignancy and autoimmune disorders. While unfractionated heparin and low molecular weight heparin (LMWH) are recommended first-line anticoagulants, evidence on the use of warfarin and direct oral anticoagulants (DOACs) remains limited.

This retrospective cohort study analyzed hospitalized patients with nonbacterial thrombotic endocarditis from January 1, 2016 to December 31, 2022 using the HCA Healthcare enterprise database. Patients receiving anticoagulation with unfractionated heparin, LMWH, warfarin, or DOACs were included. After excluding 759 patients for missing data, multiple anticoagulants, or extreme length of stay, 3130 patients remained for analysis. Primary outcomes were thromboembolic events, mortality, hospital length of stay, and intensive care unit length of stay.

No statistically significant difference in thromboembolic events (P = .599) or mortality (P = .092) was observed among anticoagulant classes. Cardiac comorbidities were associated with decreased thromboembolic risk (odds ratio 0.3879), while age, malignancy, chronic kidney disease, and cardiac history were associated with higher mortality. Mean hospital length of stay was significantly longer in patients receiving heparin or LMWH (5.94 days) compared with those on DOACs (4.41 days) or warfarin (4.54 days; P < .05). Intensive care unit length of stay did not differ by anticoagulant class.

Warfarin and DOACs may be viable alternatives to heparin-based therapy in nonbacterial thrombotic endocarditis, with comparable thromboembolic and mortality outcomes. However, heparin-based regimens were associated with longer hospital stays. Further prospective studies are warranted to guide anticoagulation strategies in nonbacterial thrombotic endocarditis.