Direct Oral Anticoagulants for Ventricular Thrombus After STEMI

While the incidence of intracavitary thrombi after acute myocardial infarction (AMI) has decreased thanks to optimized primary angioplasty times, some studies report rates of up to 6% for left ventricular thrombus (LVT) after ST-segment elevation acute coronary syndrome (STEMI). This increases to 19% in cases of anterior infarction accompanied by impaired ventricular function.

LVT is associated with a fourfold risk of systemic embolism and double the mortality rate. There have been no recent changes in clinical guidelines regarding pharmacological management; warfarin remains the drug of choice. However, evidence on the use of direct oral anticoagulants (DOACs) remains limited.

Yaser Jenab et al. conducted a randomized comparison of warfarin versus rivaroxaban in patients with STEMI complicated by LVT, supplementing their study with a meta-analysis of the available data to date.

Study Design

The study included adult patients aged 18 to 80 years with a diagnosis of LVT confirmed by echocardiography within two weeks of STEMI. Patients with contraindications to DOACs, rheumatic heart disease, antiphospholipid syndrome, cardiogenic shock, or renal impairment (<30 mL/min) were excluded.

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Patients in the rivaroxaban group received 15 mg daily, along with 75 mg of clopidogrel plus aspirin. Those in the warfarin group received warfarin along with clopidogrel plus aspirin. In both groups, aspirin was discontinued on the seventh day of treatment. Follow-up lasted for three months.

The primary endpoint was complete resolution of LVT at three months, while secondary outcomes included the proportion of patients with systemic embolism, major adverse cardiovascular events (MACE), and all-cause mortality.

Results

The study included 50 patients randomized 1:1, with an average age of 55 years, 18% of whom were women. Anterior AMI occurred in 90% of cases. At three months, LVT resolution occurred in 76% of patients treated with rivaroxaban versus 54.2% of those treated with warfarin (risk ratio [RR] 1.40, 95% confidence interval [CI]: 0.91–2.15; p = 0.12). There were no systemic embolism events, but there were two cases of clinically evident bleeding in the rivaroxaban group. Neither was classified as major bleeding.

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The meta-analysis, which included 228 patients with post-AMI LVT (excluding those in this study), showed similar results. Thrombus resolution was 80.8% in patients treated with DOACs compared to 70.5% in those treated with warfarin (RR 1.14, 95% CI: 0.98–1.32; p = 0.08). Additionally, DOACs were associated with a lower risk of hemorrhagic events (1.7% versus 8%; risk difference -0.06; 95% CI: -0.12 to 0; p = 0.005).

Conclusions: Efficacy and Safety of Anticoagulants in Post-STEMI Ventricular Thrombus Treatment

This small study conducted in Tehran demonstrated a good rate of LVT resolution with DOACs, without a significant increase in bleeding risk.

Original Title: Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials.

Reference: Jenab Y, Sadeghipour P, Mohseni-Badalabadi R, et al. Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials. EuroIntervention. 2025;21:DOI: 10.4244/EIJ-D-24-00527.