Direct Oral Anticoagulants Versus Vitamin K Antagonists for Treatment of Left Ventricular Thrombus: A Review of...

Left ventricular thrombus (LVT) remains a critical complication of acute myocardial infarction (MI), particularly in patients with anterior ST-segment elevation myocardial infarction (STEMI) and apical dysfunction. While primary percutaneous coronary intervention (PCI) has reduced its overall incidence compared with the pre-thrombolytic era, LVT continues to pose a significant risk of systemic embolization and stroke, driven by the interplay of endothelial injury, hypercoagulability, and stasis within the aneurysmal apex. This review synthesizes current evidence on the pathophysiology, diagnosis, and management of LVT. We critically evaluate diagnostic modalities, highlighting the substantial sensitivity gap between the clinical standard, transthoracic echocardiography (TTE), and the gold standard, cardiac magnetic resonance (CMR). This discrepancy has important implications for clinical decision-making, as TTE often overestimates thrombus resolution, potentially leading to the premature cessation of therapy. Therapeutically, the landscape has shifted from the empiric use of vitamin K antagonists (VKAs) toward the adoption of direct oral anticoagulants (DOACs). Thus, we analyze recent randomized data, including the Comparative Study of Oral Anticoagulation in Left Ventricular Thrombi (No-LVT) and the Rivaroxaban vs Warfarin in Acute Left Ventricular Thrombus Following Myocardial Infarction (RIVAWAR) trials, which demonstrate that DOACs are non-inferior to VKAs for embolic prevention and may offer superior resolution velocity, a crucial metric for stabilizing friable thrombi. We conclude that DOACs represent a reasonable, patient-centered alternative to warfarin. Nonetheless, future management strategies must integrate precise, serial imaging with rapid-onset anticoagulation to ensure complete histologic resolution while minimizing the hemorrhagic burden of prolonged triple antithrombotic therapy.