CCC

Left Ventricular Thrombus Resolution following Treatment by Direct Oral Anticoagulant or Warfarin in Patients with Anterior Myocardial Infarction

Dr. A. Jaidka, Dr. T. Zhu, Dr. S. Lavi, Dr. A. M. Johri

How Big of a Problem?

IJC 2016 Meta-analysis:

10,000 patients

Rate for ALL STEMI: 2.7%

Rate for ANT STEMI: 9.1%

Current Guidelines

Canada Antiplatelet 2018:

Warfarin is the only anticoagulant evaluated for the treatment of established LVT. Although NOACS are generally safer than warfarin, they have not been evaluated specifically in this context. 

USA STEMI 2013:

Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi. Class IIa

Why DOACs?

Warfarin is associated with: "frequent monitoring, slow onset, narrow therapeutic range, dietary restrictions, and multiple drug interactions associated with warfarin"

 DOACs may achieve more consistent anticoagulant effects with often decreased risk of bleeding

https://jamanetwork.com/journals/jamacardiology/article-abstract/2680628

Current Evidence?

Case Reports

Objective

The purpose of this retrospective analysis is to assess the efficacy and safety of DOACs compared to warfarin in the treatment of LV thrombus following anterior STEMI and primary PCI.  

Methods

• Retrospective observational study across 2 sites (Kingston and London) of patients diagnosed with LV thrombus following anterior STEMI from January 2015 to December 2017

• Key Points:

  • Thrombolyzed or PCI

  • Echo within 1 week and definitive LV thrombus

Outcomes

Primary efficacy outcome was stroke, transient ischemic attack (TIA) or systemic embolism. 

Primary safety outcome was major bleeding and thrombus resolution

Incidence of 6.3%

Limitations

• Retrospective design and small sample size

• Incomplete Follow-up TTE and was not blinded to the anticoagulant regiment

• Initial preference between warfarin and DOAC therapy was not captured

Conclusion

This small retrospective study yields a very important signal that the use of DOACs in treatment of LV thrombus following anterior STEMI was effective in thrombus resolution on follow-up echocardiogram at 3 months. This is the first study we are aware of to show potential equivalence and is critical in supporting the need for a large multi-center, prospective study comparing DOACs to warfarin.

Questions?