Comparison of direct oral anticoagulants and vitamin K antagonists in the treatment of left ventricular thrombi: a retrospective cohort study.

BACKGROUND

Left ventricular thrombus (LVT) is a serious thromboembolic complication in patients with cardiomyopathies. Evidence supporting direct oral anticoagulant (DOAC) therapy in LVT is limited.

OBJECTIVES

We evaluated the effectiveness and safety of DOACs compared with vitamin K antagonists (VKAs) in patients with LVT.

METHODS

A multisite retrospective cohort study was performed, including patients with LVT diagnosed by echocardiography from 2018-2023 who were treated with either DOACs or VKAs. Primary outcome was the incidence of stroke and systemic embolism (SSE). Secondary outcomes included LVT resolution, major bleeding, and all-cause mortality.

RESULTS

A total of 182 patients with LVT met inclusion criteria, of which 70 (38.5%) were treated with only DOACs and 112 (61.5%) with only VKAs. The mean age was 66 years, and 74% of the patients were male. The median follow-up duration was 363.5 days (IQR, 139-950). No significant difference between the groups was observed in the incidence of SSE (DOAC, 5.7% vs VKA, 5.4%; P = 1.0), the incidence of LVT resolution (DOAC: 81.4% vs VKA: 87%; P = .35), the median time to LVT resolution (DOAC, 96 days vs VKA, 102 days; P = .22), or mortality (DOAC, 14.3% vs VKA, 11.6%; P = .6). However, VKAs were associated with a significantly higher incidence of major bleeding compared with DOACs (9% vs 1.4%; P = .02).

CONCLUSION

LVT treated solely with either DOACs or VKAs had similar incidences of SSE, LVT resolution, time to LVT resolution, and mortality. VKA therapy, however, was associated with a higher incidence of major bleeding events.