Direct oral anticoagulants or warfarin in left ventricular thrombus: an updated systematic review and meta-analysis of randomized trials.

Left ventricular thrombus (LVT) is a significant complication following acute myocardial infarction (AMI), posing substantial risks of stroke and systemic embolism. Warfarin remains the traditional standard for anticoagulation, but direct oral anticoagulants (DOACs) have emerged as practical alternatives despite limited comparative evidence. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of DOACs versus warfarin in patients with LVT. We systematically searched PubMed, Embase, and Cochrane databases for RCTs comparing DOACs and warfarin in patients with LVT. Outcomes of interest included thrombus resolution rates at 1- and 3-month follow-up and safety outcomes, including major bleeding, stroke/systemic embolism, and all-cause mortality. We included 7 RCTs comprising 554 patients, of whom 319 received DOACs. No significant differences were found between DOACs and warfarin regarding LVT resolution at 1 month (OR: 1.69; 95% CI: 0.62–4.60; p = 0.31; I²=69%) or 3 months (OR: 1.39; 95% CI: 0.82–2.37; p = 0.22; I²=0%). Secondary outcomes, including major bleeding (OR: 0.51; 95% CI: 0.12–2.12), stroke/systemic embolism (OR: 0.69; 95% CI: 0.10–4.64), and all-cause mortality (OR: 0.86; 95% CI: 0.31–2.40), were also similar between groups. In patients with LVT, DOACs demonstrated comparable efficacy and safety to warfarin, offering practical advantages such as simplified management. These findings support DOACs as a reasonable alternative to warfarin for treating LVT. However, further large-scale trials using advanced imaging and standardized anticoagulation protocols are warranted.