Current concepts of treatment for left ventricular thrombus: A sys-tematic meta-analysis comparing direct oral anticoagulants versus vitamin K-antagonists

Abstract Background/Introduction Left ventricular thrombus (LVT) is a dreaded complication after myocardial infarction (MI) and is traditionally treated with Vitamin K antagonists (VKAs) for 3-6 months. Despite a gap of evidence, the broad use of direct oral anticoagulants (DOACs) for other thromboembolic disorders has triggered an increasing off-label use for DOACs in LVTs and has stimulated for expanding research focusing on DOAC´s utility for patients with LVT. Purpose To assess the safety and efficacy of DOACs versus VKAs for the treatment of LVT with a systematic meta-analysis. Methods We conducted a systematic search according to the PRISMA guidelines to identify all existing studies comparing DOACs and VKAs for the treatment of LVT. Forest plots and pooled odds ratios have been calculated for major bleeding events, strokes and systemic embolism, and for thrombus resolution. Results We have included a total of 13 studies with a pooled sample size of 2243 patients. 601 patients (26.8%) were treated with DOACs and 1642 patients (73.2%) with VKAs. The mean age was 55 and 59 years in the DOACs and VKAs group and sex was equally distributed with a male predominance of 81% in both groups. As underlying heart disease, most patients suffered from acute or chronic ischemic cardiomyopathy and presented with a mean left ventricular ejection fraction (LVEF) of 32% at admission. Baseline characteristics of patients included in each primary study are summarized in table 1. The pooled odds ratio of stroke or systemic embolism in patients treated with DOACs versus VKAs was 0.84 (95% CI 0.59-1.19) (p= 0.32). Compared to VKAs, we suggest that the use of DOACs may be associated with a reduced risk for major bleeding incidents without reaching statistical significance (OR 0.63 (95% CI 0.39-1.04) (p = 0.07). LVT resolution was similar and independent of the antithrombotic regimen (OR 0.91 (95% CI 0.7-1.19), p=0.50). Conclusions Based on our meta-analysis we conclude that DOACs seem to be non-inferior to VKAs for the treatment of LVT in terms of thrombus resolution, stroke and systemic embolism, and bleeding incidents. Despite these promising findings, several important aspects such as the duration of anticoagulation, and the type and dosing of the DOAC agent are still poorly understood. To close the lack of evidence for DOACs in LVTs, an adequately powered, randomized trial is needed.