Comparison of Direct Oral Anticoagulants and Vitamin K Antagonists for Left Ventricular Thrombus: A Global Retrospective Study.

Introduction: Guidelines for managing left ventricular thrombus remain limited, particularly when incorporating oral anticoagulants into dual antiplatelet therapy for acute myocardial infarction. This study aims to assess the safety and efficacy of direct oral anticoagulants (DOACs) vs vitamin K antagonists (VKAs) in managing left ventricular thrombus among patients with and without recent myocardial infarction.

Methods: This retrospective observational study used data from the TriNetX research network. Patients with left ventricular thrombus treated with either DOACs or VKAs between December 1, 2013 and December 1, 2023, were included. Subgroup analyses were conducted for patients with or without recent acute coronary syndrome (<1 month). Risk and Kaplan-Meier survival analysis were conducted at 90 days after the indexed event.

Results: A total of 39,770 patients were included. DOACs treatment had lower rates of stroke (11.8% vs 13.7%; relative risk [RR] 0.859; 95% confidence interval [CI], 0.816-0.905; P < .001), major bleeding (4.8% vs 5.3%; RR 0.902; 95% CI, 0.829-0.982; P = .018), and systemic embolism (3.5% vs 4.2%; RR 0.841; 95% CI, 0.762-0.928; P = .001) compared with VKAs in overall cohort. Within the acute coronary syndrome group (n = 14,302), DOACs had lower stroke (12.3% vs 14.4%, RR 0.860; 95% CI, 0.791-0.935; P < .0001) and systemic embolism (3.1% vs 4%; RR 0.774; 95% CI, 0.651-0.919; P = .003) risks. For non-acute coronary syndrome group (n = 24,162), DOACs had lower stroke (11.4% vs 13.1%; RR 0.868; 95% CI, 0.811-0.929; P < .001) and major bleeding (4.8% vs 5.5%; RR 0.877; 95% CI, 0.787-0.977; P = .017) risks. No significant differences in all-cause mortality were observed across groups.

Conclusion: DOACs demonstrated better safety and efficacy outcomes when compared with VKAs in left ventricular thrombus treatment, with or without recent acute coronary syndrome.