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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 Publisher Pubmed



Jenab Y1 ; Sadeghipour P2, 3 ; Mohsenibadalabadi R1 ; Kaviani R4 ; Hosseini K1 ; Pasebani Y2 ; Khederlou H1 ; Rafati A2, 5 ; Mohammadi Z1 ; Jamalkhani S2 ; Talasaz AHH6, 7, 8 ; Firouzi A5 ; Ariannejad H1 ; Alemzadehansari MJ5 Show All Authors
Authors
  1. Jenab Y1
  2. Sadeghipour P2, 3
  3. Mohsenibadalabadi R1
  4. Kaviani R4
  5. Hosseini K1
  6. Pasebani Y2
  7. Khederlou H1
  8. Rafati A2, 5
  9. Mohammadi Z1
  10. Jamalkhani S2
  11. Talasaz AHH6, 7, 8
  12. Firouzi A5
  13. Ariannejad H1
  14. Alemzadehansari MJ5
  15. Ahmadirenani S1
  16. Maadani M5
  17. Farrashi M2, 4
  18. Bakhshandeh H2, 3
  19. Piazza G9, 10
  20. Krumholz HM11, 12
  21. Mehran R13
  22. Lip GYH14, 15
  23. Bikdeli B9, 10, 12
Show Affiliations
Authors Affiliations
  1. 1. Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
  2. 2. Vascular Disease and Thrombosis Research Center, Rajaie Cardiovascular Institute, Tehran, Iran
  3. 3. Clinical Trial Center, Rajaie Cardiovascular Institute, Tehran, Iran
  4. 4. Echocardiography Research Center, Rajaie Cardiovascular Institute, Tehran, Iran
  5. 5. Cardiovascular Intervention Research Center, Rajaie Cardiovascular Institute, Tehran, Iran
  6. 6. Department of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, NY, USA
  7. 7. Department of Pharmacy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
  8. 8. Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, United States
  9. 9. Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
  10. 10. Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
  11. 11. Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
  12. 12. Yale/YNHH Center for Outcomes Research & Evaluation (CORE), New Haven, CT, United States
  13. 13. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
  14. 14. Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
  15. 15. Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark

Source: EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology Published:2025


Abstract

BACKGROUND: The role of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT) after ST-elevation myocardial infarction (STEMI) remains uncertain. AIMS: We aimed to compare the effect of rivaroxaban versus warfarin in patients with STEMI complicated by LVT. METHODS: Adult patients with STEMI and two-dimensional transthoracic echocardiography showing LVT were assigned to rivaroxaban (15 mg once daily) or warfarin (international normalised ratio goal of 2.0-2.5) in an open-label, randomised clinical trial (RCT). A prospective pooled analysis was planned comparing DOAC- versus warfarin-based anticoagulation for the same indication. The main outcome of the RCT was complete LVT resolution at 3 months, determined by a blinded imaging core laboratory. Complete LVT resolution and bleeding were investigated in the pooled analysis. RESULTS: A total of 50 patients (median age: 55 years, 18% females) were enrolled from June 2020 to November 2022. Three-month complete LVT resolution occurred in 19/25 (76.0%) patients assigned to rivaroxaban and 13/24 (54.2%) assigned to warfarin (relative risk [RR] 1.40, 95% confidence interval [CI]: 0.91-2.15; p=0.12) with no thrombotic or major bleeding events. Pooled analysis showed numerically better complete LVT resolution with DOACs (rivaroxaban and apixaban; 93/115 [80.8%] vs 79/112 [70.5%], RR 1.14, 95% CI: 0.98-1.32; p=0.08) and less major bleeding (2/116 [1.7%] and 9/112 [8.0%], risk difference -0.06, 95% CI: -0.12 to 0.00; p=0.05) than with warfarin. CONCLUSIONS: Although the findings are limited by a small sample size, the results suggest that DOACs are safe with at least similar outcomes concerning LVT resolution and major bleeding compared with warfarin. (ClinicalTrials.gov: NCT05705089).