Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists.
Administration, Oral
Adult
Aged
Anticoagulants
/ therapeutic use
Arrhythmias, Cardiac
/ drug therapy
Female
Fibrinolytic Agents
/ administration & dosage
Heart Failure
/ drug therapy
Humans
Male
Middle Aged
Myocardial Infarction
/ drug therapy
Retrospective Studies
Stroke
/ drug therapy
Thrombosis
/ drug therapy
Vitamin K
/ antagonists & inhibitors
Journal
Clinical drug investigation
ISSN: 1179-1918
Titre abrégé: Clin Drug Investig
Pays: New Zealand
ID NLM: 9504817
Informations de publication
Date de publication:
Apr 2020
Apr 2020
Historique:
pubmed:
8
3
2020
medline:
19
8
2020
entrez:
8
3
2020
Statut:
ppublish
Résumé
The efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular (LV) thrombi remains to be determined, especially in patients with ischemic cardiomyopathy. This retrospective study sought to compare the efficacy of vitamin K antagonists (VKAs) and DOACs in patients with LV thrombi and evaluate the rate of LV thrombus resolution after adjusting anticoagulation. This observational retrospective study included patients admitted to our institution for LV thrombus between January 2010 and August 2019. The rate of LV thrombus resolution was compared between VKAs and DOACs. Patients without thrombus resolution with DOAC treatment were switched to VKA agents in order to obtain an international normalized ratio (INR) of 3-4. Between January 2010 and August 2019, 59 consecutive patients with LV thrombi detected by transthoracic echocardiography were included in the study. The mean age was 62 ± 14 years and 16.9% were women. The circumstances of LV thrombus discovery were as follows: acute myocardial infarction or ischemic myocardiopathy (n = 22), stroke (n = 6), chest pain (n = 7), heart failure (n = 11), transthoracic echocardiographic evaluation (n = 11), and ventricular arrhythmias (n = 2). The proportion of patients on DOACs was 28.8% (n = 17), while that of those on VKAs was 71.2% (n = 42). Thrombus resolution was obtained in 70.6% (12/17) of patients on DOACs and in 71.4% (30/42) of those on VKAs (p = 0.9). Patients who failed to respond to DOAC treatment were treated with VKAs, and following this treatment adjustment all LV thrombi were dissolved in the DOAC group (5/5). Five embolic events (8.4% of stroke) occurred before the treatment initiation and six with anticoagulants (2/17 with DOACs [11.8%] and 4/42 with VKAs [9.5%]; p = 0.8). This retrospective observational study found a similar efficacy between DOAC and VKA agents in patients with LV thrombi (70.6% vs. 71.5%); however, when the thrombus remains, VKAs are still the standard of care as it is possible to control INR levels (3-4) with them.
Sections du résumé
BACKGROUND AND OBJECTIVES
OBJECTIVE
The efficacy of direct oral anticoagulants (DOACs) in the management of left ventricular (LV) thrombi remains to be determined, especially in patients with ischemic cardiomyopathy. This retrospective study sought to compare the efficacy of vitamin K antagonists (VKAs) and DOACs in patients with LV thrombi and evaluate the rate of LV thrombus resolution after adjusting anticoagulation.
METHODS
METHODS
This observational retrospective study included patients admitted to our institution for LV thrombus between January 2010 and August 2019. The rate of LV thrombus resolution was compared between VKAs and DOACs. Patients without thrombus resolution with DOAC treatment were switched to VKA agents in order to obtain an international normalized ratio (INR) of 3-4.
RESULTS
RESULTS
Between January 2010 and August 2019, 59 consecutive patients with LV thrombi detected by transthoracic echocardiography were included in the study. The mean age was 62 ± 14 years and 16.9% were women. The circumstances of LV thrombus discovery were as follows: acute myocardial infarction or ischemic myocardiopathy (n = 22), stroke (n = 6), chest pain (n = 7), heart failure (n = 11), transthoracic echocardiographic evaluation (n = 11), and ventricular arrhythmias (n = 2). The proportion of patients on DOACs was 28.8% (n = 17), while that of those on VKAs was 71.2% (n = 42). Thrombus resolution was obtained in 70.6% (12/17) of patients on DOACs and in 71.4% (30/42) of those on VKAs (p = 0.9). Patients who failed to respond to DOAC treatment were treated with VKAs, and following this treatment adjustment all LV thrombi were dissolved in the DOAC group (5/5). Five embolic events (8.4% of stroke) occurred before the treatment initiation and six with anticoagulants (2/17 with DOACs [11.8%] and 4/42 with VKAs [9.5%]; p = 0.8).
CONCLUSIONS
CONCLUSIONS
This retrospective observational study found a similar efficacy between DOAC and VKA agents in patients with LV thrombi (70.6% vs. 71.5%); however, when the thrombus remains, VKAs are still the standard of care as it is possible to control INR levels (3-4) with them.
Identifiants
pubmed: 32144651
doi: 10.1007/s40261-020-00898-3
pii: 10.1007/s40261-020-00898-3
doi:
Substances chimiques
Anticoagulants
0
Fibrinolytic Agents
0
Vitamin K
12001-79-5
Types de publication
Comparative Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
343-353Références
Solheim S, Seljeflot I, Lunde K, et al. Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy. Am J Cardiol. 2010;106:1197–200.
doi: 10.1016/j.amjcard.2010.06.043
Mao TF, Bajwa A, Muskula P, et al. Incidence of left ventricular thrombus in patients with acute ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. Am J Cardiol. 2018;121(1):27–31.
doi: 10.1016/j.amjcard.2017.09.010
Kupper AJ, Verheugt FW, Peels CH, Galema TW, Roos JP. Left ventricular thrombus incidence and behavior studied by serial two-dimensional echocardiography in acute anterior myocardial infarction: left ventricular wall motion, systemic embolism and oral anticoagulation. J Am Coll Cardiol. 1989;13:1514–20.
doi: 10.1016/0735-1097(89)90341-0
Gianstefani S, Douiri A, Delithanasis I, et al. Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention. Am J Cardiol. 2014;113(7):1111–6.
doi: 10.1016/j.amjcard.2013.12.015
Robinson AA, Jain A, Gentry M, McNamara RL. Left ventricular thrombi after STEMI in the primary PCI era: a systematic review and meta-analysis. Int J Cardiol. 2016;221:554–9.
doi: 10.1016/j.ijcard.2016.07.069
Maniwa N, Fujino M, Nakai M, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J. 2018;39(3):201–8.
doi: 10.1093/eurheartj/ehx551
Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol. 1993;22(4):1004–9.
doi: 10.1016/0735-1097(93)90409-T
Steg PG, James SK, Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC), et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569–619.
doi: 10.1093/eurheartj/ehs215
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119–77.
doi: 10.1093/eurheartj/ehx393
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th edn: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):7S–47S.
doi: 10.1378/chest.1412S3
pubmed: 3278060
pmcid: 3278060
Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625–51.
doi: 10.1093/europace/eut083
Aydin F, Turgay Yildirim O, Huseyinoglu Aydin A, Dagtekin E, Aksit E. Is rivaroxaban a safe choice for apical thrombus in atrial fibrillation patients? A case report. J Stroke Cerebrovasc Dis. 2018;27(9):e203–5.
doi: 10.1016/j.jstrokecerebrovasdis.2018.04.015
Noflatscher M, Moes N, Gassner EM, Marschang P. Dabigatran added to dual antiplatelet therapy to treat a left ventricular thrombus in an 87 year old patient with myocardial infarction and very high bleeding risk. Front Pharmacol. 2018;4(9):217.
doi: 10.3389/fphar.2018.00217
Elikowski W, Małek-Elikowska M, Fertała N, Zawodna M, Kruzel K. Fast apixaban-related resolution of left ventricular thrombi in a patient with dilated cardiomyopathy. Pol Merkur Lekarski. 2018;44(259):19–22.
pubmed: 29374418
Sun H, Zhao Q, Wang Y, et al. Daily 10 mg rivaroxaban as a therapy for ventricular thrombus related to left ventricular non-compaction cardiomyopathy: a case report. Medicine (Baltimore). 2018;97(4):e9670.
doi: 10.1097/MD.0000000000009670
Adar A, Onalan O, Cakan F. Newly developed left ventricular apical thrombus under dabigatran treatment. Blood Coagul Fibrinol. 2018;29(1):126–8.
doi: 10.1097/MBC.0000000000000671
Smetana KS, Dunne J, Parrott K, et al. Oral factor Xa inhibitors for the treatment of left ventricular thrombus: a case series. J Thromb Thromb. 2017;44(4):519–24.
doi: 10.1007/s11239-017-1560-7
Seecheran R, Seecheran V, Persad S, Seecheran NA. Rivaroxaban as an antithrombotic agent in a patient with ST-segment elevation myocardial and left ventricular thrombus: a case report. J Investig Med High Impact Case Rep. 2017;5(1):2324709617697991.
pubmed: 5433551
pmcid: 5433551
Elikowski W, Małek-Elikowska M, Słomczyński M, Ganowicz-Kaatz T, Bolewski A, Skrzywanek P. Rivaroxaban-resistant right ventricular thrombus, successfully treated with vitamin K antagonist in a patient with dilated cardiomyopathy. Pol Merkur Lekarski. 2016;41(245):238–42.
pubmed: 27883351
Makrides CA. Resolution of left ventricular postinfarction thrombi in patients undergoing percutaneous coronary intervention using rivaroxaban in addition to dual antiplatelet therapy. BMJ Case Rep. 2016;2016:bcr2016217843.
Kaya A, Hayıroğlu Mİ, Keskin M, Tekkeşin Aİ, Alper AT. Resolution of left ventricular thrombus with apixaban in a patient with hypertrophic cardiomyopathy. Turk Kardiyol Dern Ars. 2016;44(4):335–7.
pubmed: 27372620
Kolekar S, Munjewar C, Sharma S. Dabigatran for left ventricular thrombus. Indian Heart J. 2015;67(5):495–6.
doi: 10.1016/j.ihj.2015.06.010
pubmed: 4593802
pmcid: 4593802
Ohashi N, Okada T, Uchida M, Amioka M, Fujiwara M, Kaseda S. effects of dabigatran on the resolution of left ventricular thrombus after acute myocardial infarction. Intern Med. 2015;54(14):1761–3.
doi: 10.2169/internalmedicine.54.4191
Mano Y, Koide K, Sukegawa H, Kodaira M, Ohki T. Successful resolution of a left ventricular thrombus with apixaban treatment following acute myocardial infarction. Heart Vessels. 2016;31(1):118–23.
doi: 10.1007/s00380-014-0562-z
Padilla Pérez M, Salas Bravo D, Garcelán Trigo JA, et al. Resolution of left ventricular thrombus by rivaroxaban. Future Cardiol. 2014;10(3):333–6.
doi: 10.2217/fca.14.12
Nagamoto Y, Shiomi T, Matsuura T, et al. Resolution of a left ventricular thrombus by the thrombolytic action of dabigatran. Heart Vessels. 2014;29(4):560–2.
doi: 10.1007/s00380-013-0403-5
Kaku B. Intra-cardiac thrombus resolution after anti-coagulation therapy with dabigatran in a patient with mid-ventricular obstructive hypertrophic cardiomyopathy: a case report. J Med Case Rep. 2013;7:238.
doi: 10.1186/1752-1947-7-238
pubmed: 3851832
pmcid: 3851832
Chung K, Paek YM, Lee HJ, Hong K-S. Dabigatran effect on left ventricular thrombus in a patient with acute ischemic stroke. J Stroke. 2015;17(3):366–8.
doi: 10.5853/jos.2015.17.3.366
pubmed: 4635718
pmcid: 4635718
Nakasuka K, Ito S, Noda T, et al. Resolution of left ventricular thrombus secondary to tachycardia-induced heart failure with rivaroxaban. Case Rep Med. 2014;2014:814524.
doi: 10.1155/2014/814524
pubmed: 4247908
pmcid: 4247908
Cross P, Stewart R. Left ventricular mural thrombus treated with dabigatran. J Case Rep Stud. 2014;2(4):402.
Berry A, Brancheau D, Zughaib M. Rapid resolution of left ventricular thrombus with apixaban therapy. SAGE Open Med Case Rep. 2017;5:2050313X17745211.
Abubakar H, Yassin AS, Shokr M. Rivaroxaban used for treatment of a left ventricular thrombus in a patient with nonischemic cardiomyopathy. Am J Ther. 2018;25(6):e706–9.
doi: 10.1097/MJT.0000000000000722
Da Costa A, Delolme C, Guichard JB, et al. Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation. Am Heart J. 2017;193:8–15.
doi: 10.1016/j.ahj.2017.07.016
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39.
doi: 10.1016/j.echo.2014.10.003
Weinsaft JW, Kim HW, Crowley AL, et al. LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR. JACC Cardiovasc Imaging. 2011;4(7):702–12.
doi: 10.1016/j.jcmg.2011.03.017
pubmed: 3724234
pmcid: 3724234
Pöss J, Desch S, Eitel C, de Waha S, Thiele H, Eitel I. Left ventricular thrombus formation after ST-segment-elevation myocardial infarction: insights from a cardiac magnetic resonance multicenter study. Circ Cardiovasc Imaging. 2015;8(10):e003417.
doi: 10.1161/CIRCIMAGING.115.003417
Phan J, Nguyen T, French J, et al. Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: a serial cardiac MRI study. Int J Cardiol Heart Vasc. 2019;24:100395.
pubmed: 6612928
pmcid: 6612928
Merkler AE, Alakbarli J, Gialdini G, et al. Short-term risk of ischemic stroke after detection of left ventricular thrombus on cardiac magnetic resonance imaging. J Stroke Cerebrovasc Dis. 2019;28(4):1027–31.
doi: 10.1016/j.jstrokecerebrovasdis.2018.12.025
Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2014;45(7):2160–236.
doi: 10.1161/STR.0000000000000024
Dewilde WJM, Oirbans T, Verheugt FWA, WOEST Study Investigators, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107–15.
doi: 10.1016/S0140-6736(12)62177-1
Bulluck H, Chan MHH, Paradies V, et al. Incidence and predictors of left ventricular thrombus by cardiovascular magnetic resonance in acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: a meta-analysis. J Cardiovasc Magn Reson. 2018;20(1):72.
doi: 10.1186/s12968-018-0494-3
pubmed: 6222991
pmcid: 6222991
Fleddermann AM, Hayes CH, Magalski A, Main ML. Efficacy of direct acting oral anticoagulants in treatment of left ventricular thrombus. Am J Cardiol. 2019;124(3):367–72.
doi: 10.1016/j.amjcard.2019.05.009
Bahmaid RA, Ammar S, Al-Subaie S, Soofi MA, Mhish H, Yahia MA. Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus-a case series and literature review. JRSM Cardiovasc Dis. 2019;8:2048004019839548.
pubmed: 6456843
pmcid: 6456843
Yildirim E, Kalkan K, Ipek E, Demirelli S, Ermiş E. Successful resolution of left ventricular thrombus with apixaban treatment. Int J Cardiovasc Acad. 2016;2:57–8.
doi: 10.1016/j.ijcac.2015.12.004
Azizi A, Puricel S, Cook S, Brugger N. Rivaroxaban dissolves postinfarction left ventricular thrombus. Cardiovasc Med. 2016;19:25–7.
doi: 10.4414/cvm.2016.00381
Shokr M, Ahmed A, Abubakar H, et al. Use of direct oral anticoagulants in the treatment of left ventricular thrombi: a tertiary center experience and review of the literature. Clin Case Rep. 2019;7(1):135–42.
doi: 10.1002/ccr3.1917
Cheong K-I, Chuang W-P, Wu Y-W, Huang S-H. Successful resolution of left ventricular thrombus after ST-elevation myocardial infarction by edoxaban in a patient with high bleeding risk. Acta Cardiol Sin. 2019;35(1):85–8.
pubmed: 6342836
pmcid: 6342836
Abdelnaby M, Almaghraby A, Abdelkarim O, Saleh Y, Hammad B, Badran H. The role of rivaroxaban in left ventricular thrombi. Anatol J Cardiol. 2019;21(1):47–50.
pubmed: 6382905
pmcid: 6382905
Yamamoto T, Konishi T, Funayama N, Kikuchi B, Hotta D, Ohori K. Resolution of left ventricular thrombus after dabigatran therapy in two patients with old anteroseptal myocardial infarction. Cardiol Pharmacol. 2015;4:152.
doi: 10.4172/2329-6607.1000152
Elikowski W, Małek-Elikowska M, Wróblewski D, et al. Apixaban in left ventricular thrombi treatment—a report of seven cases. Pol Merkur Lekarski. 2018;44(264):276–9.
pubmed: 30057394
Kao P-H, Chou P-Y, Hsu P-C, Huang T-C. Resolution of left ventricular thrombus by edoxaban after failed treatment with warfarin overdose: a case report. Medicine (Baltimore). 2019;98(2):e14065.
doi: 10.1097/MD.0000000000014065
Huang L-Y, Chang T-H, Wu C-H, Tsai T-N. Warfarin-resistant left ventricular thrombus completely dissolved by rivaroxaban. Br J Hosp Med (Lond). 2018;79(11):648–9.
doi: 10.12968/hmed.2018.79.11.648
Bennett S, Satchithananda D, Law G. The use of apixaban for the treatment of an LV thrombus. Echo Res Pract. 2018;5(4):K63–6.
doi: 10.1530/ERP-18-0036
pubmed: 6130431
pmcid: 6130431
Nafee T, Aslam A, Chi G, et al. Andexanet alfa for the reversal of anticoagulant activity in patients treated with direct and indirect factor Xa inhibitors. Expert Rev Cardiovasc Ther. 2017;15(4):237–45.
doi: 10.1080/14779072.2017.1305889
Lip G, Hammerstingl C, Marin F, X-TRA Study and CLOT-AF Registry Investigators, et al. Left atrial thrombus resolution in atrial fibrillation or flutter: results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J. 2016;178:126–34.
doi: 10.1016/j.ahj.2016.05.007