Direct Oral Anticoagulation versus Warfarin in Left Ventricular Thrombus: Pooled Analysis of Randomized Controlled Trials.

Patients with impaired left ventricular (LV) function can develop LV thrombus, a potentially life-threatening condition due to risk of stroke and embolization. Conventional treatment with vitamin K antagonists (VKA; e.g., warfarin) puts patients at risk of bleeding, and the use of direct oral anticoagulants (DOAC) appears promising, although data are scant. We searched the published English language literature for randomized controlled trials (RCT) comparing DOAC vs. VKA in LV thrombus. Endpoints were failure-to-resolve, thromboembolic events (stroke, embolism), bleeding, or any adverse event (composite of thromboembolism or bleeding), or all-cause death. Data were pooled and analyzed in hierarchical Bayesian models. In 3 eligible RCTs, n = 141 patients were studied during an average of 4.6 months (53.8 patient-years; n = 71 assigned to DOAC, n = 70 assigned to VKA). A similar number of patients in each treatment arm demonstrated failure-to-resolve (DOAC: 14/71 vs. VKA: 15/70) and death events (3/71 vs. 4/70). However, patients on DOAC suffered fewer stroke / thromboembolic events (1/71 vs. 7/70; log odds ratio (OR) -2.02 (95% credible interval (CI95): -4.53 - -0.31)) and fewer bleeding events (2/71 vs. 9/70; log OR -1.62 (CI95: -3.43 - -0.26)), leading to fewer patients on DOAC with any adverse event vs. VKA (3/71 vs. 16/70; log OR -1.93 (CI95: -3.33 - -0.75)). In conclusion, pooled analysis of RCT data favors DOAC over VKA in patients with LV thrombus both in terms of efficacy and safety. This article is protected by copyright. All rights reserved.