NOACs vs warfarin for LV thrombus after acute myocardial infarction

  • Jones DA & al.
  • Eur Heart J Cardiovasc Pharmacother
  • 10 Aug 2020

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • Novel oral anti-coagulants (NOACs) demonstrated improved left ventricular (LV) thrombus resolution post-acute myocardial infarction (AMI) compared with vitamin K antagonist (VKA).
  • Major bleeding events were lower with NOACs vs VKA (warfarin).

Why this matters

  • Current guidelines recommend the use of VKA for LV thrombus post-AMI.
  • However, based on evidence supporting non-inferiority of NOACs vs VKA for prevention of thromboembolic events in atrial fibrillation, NOACs are being increasingly used off licence for LV thrombus post-AMI.
  • Findings warrant randomised controlled trials to confirm this observational data.

Study design

  • An observational study of 2328 patients with AMI who underwent coronary angiography +/− percutaneous coronary intervention between 2015-2018.
  • Primary outcome: resolution of LV thrombus.
  • Secondary outcomes: bleeding events (defined by Bleeding Academic Research Consortium criteria) and thromboembolic events.
  • Funding: None disclosed.

Key results

  • Overall, 101 (4.3%) patients were diagnosed with LV thrombus.
  • Of 101 patients, 60 (59.4%) were treated with warfarin and 41 (40.6%) with NOAC therapy (rivaroxaban, 58.5%; apixaban, 36.5%; and edoxaban, 5%).
  • Overall rates of LV thrombus resolution were 86.1% over the follow-up period (median, 2.2 years).
  • NOAC vs VKA group had a greater and earlier LV thrombus resolution (82% vs 64.4% at 1 year; P=.0018), which persisted after adjusting for baseline variables (OR, 1.8; 95% CI, 1.2-2.9).
  • The incidence of major bleeding events was lower in the NOAC vs VKA group (0% vs 6.7%; P=.030), with no difference in rates of systemic thromboembolism (2.4% vs 5%; P=.388).

Limitations

  • Small sample size; non-randomised design.
  • Risk of residual confounding.