Direct oral anticoagulants vs vitamin K antagonist for left ventricular thrombus

  • Iqbal H & al.
  • ESC Heart Fail
  • 25 Jun 2020

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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  • In patients with left ventricular (LV) thrombus, direct oral anticoagulants (DOACs) are likely to be as effective and safe as vitamin K antagonist (VKA) for stroke prevention and, despite their lack of a licence for this indication, are therefore likely to represent a reasonable and more convenient option for this setting.

Why this matters

  • Findings warrant future prospective, randomised trials to explore the optimal timing and type of anticoagulation for LV thrombus, as well as the role of screening for high-risk patients.

Study design

  • This retrospective, observational cohort study included 84 patients diagnosed with LV thrombus; 62 received VKA (warfarin) and 22 DOAC including 13 prescribed rivaroxaban, eight apixaban, and one dabigatran.
  • Primary outcome: thromboembolic events and clinically significant bleeding.
  • Secondary outcomes: thrombus resolution on repeat cardiac imaging, all-cause mortality, and repeat hospitalisation.
  • Funding: None disclosed.

Key results

  • Overall, 55 patients (65%) were co-prescribed a single antiplatelet agent and 32 (38%) received dual-antiplatelet therapy.
  • During an average follow-up of 3.0±1.4 years, no statistically significant differences were observed between VKA and DOACs in:
    • rates of stroke (2% vs 0%; P=.55);
    • other thromboemboli (2% vs 0%; P=.55); and
    • clinically significant bleeding (10% vs 0%; P=.13).
  • The mean duration between diagnosis and repeat imaging was 233 ± 251 days with no difference between groups (P=.83).
  • The rate of resolution of thrombus (76% vs 65%; P=.33), rehospitalisation (50% vs 45%; P=.53), and all-cause mortality (10% vs 14%; P=.61) did not differ between groups.


  • Retrospective design.
  • Small sample size.