Efficacy and safety of direct oral anticoagulants versus warfarin in patients with a left ventricular thrombus: an updated systematic review and meta-analysis of randomised controlled trials.

BACKGROUND

Left ventricular (LV) thrombus is a complication of myocardial infarction and dilated cardiomyopathy and is associated with a high thromboembolic risk. Although warfarin has traditionally been used, direct oral anticoagulants (DOACs) offer a more convenient alternative. With the addition of the RIVAWAR trial, we conducted an updated systematic review and meta-analysis to assess the efficacy and safety of DOACs compared with warfarin in patients with LV thrombus.

METHODS

A systematic search of electronic databases (PubMed, EMBASE, Cochrane and clinicaltrials.gov) from inception to April 2025 identified randomised clinical trials (RCTs) comparing DOACs with warfarin for the treatment of LV thrombus. The main outcome of interest was thrombus resolution at 3 months. Risk ratios (RRs) with 95% CIs were calculated using random-effects models.

RESULTS

Seven RCTs comprising 554 patients were included. Non-contrast transthoracic echocardiography was used for LV thrombus assessment in all RCTs. There was no difference between DOACs and warfarin in thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09), major adverse cardiovascular events (RR 0.50; 95% CI 0.16 to 1.54), all-cause mortality (RR 0.92; 95% CI 0.36 to 2.31), stroke/systemic embolism (RR 0.76; 95% CI 0.12 to 4.68), rehospitalisation (RR 1.36; 95% CI 0.47 to 3.94) or major bleeding (RR 0.54; 95% CI 0.20 to 1.48). Subgroup and sensitivity analyses confirmed the robustness of these results.

CONCLUSIONS

DOACs demonstrated similar efficacy and safety to warfarin for LV thrombus management in this meta-analysis, supporting their use for the treatment of LV thrombus. However, large-scale RCTs with longer follow-up periods and using diagnostic modalities with higher sensitivity and specificity for detecting LV thrombus resolution are warranted to confirm these findings and clarify long-term outcomes.

PROSPERO REGISTRATION NUMBER: CRD420251023513.