Direct oral anticoagulants (DOACs) are not currently recommended for the treatment of left ventricular thrombus (LVT) due to limited evidence and a potential increased risk of stroke or systemic embolism (SSE) compared to warfarin.
Current guidelines and evidence
- The American Heart Association (AHA) and American Stroke Association (ASA) 2021 guidelines recommend initiating anticoagulation with therapeutic warfarin for at least three months to reduce the risk of recurrent stroke in patients with stroke or transient ischemic attack (TIA) and left ventricular thrombus
- A multicenter cohort study found that DOAC treatment was associated with a higher risk of SSE compared to warfarin use in patients with left ventricular thrombi, even after adjustment for other factors
- There are no high-quality data on the effectiveness of DOACs for the indication of left ventricular thrombi, and the assumption of DOAC equivalence with warfarin for this condition is challenged by current evidence
DOACs in other conditions
- DOACs are recommended over warfarin in most patients with non-valvular atrial fibrillation (NVAF) requiring oral anticoagulation, according to guidelines from the Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS/CHRS) 2020 and the Cardiac Society of Australia and New Zealand/National Heart Foundation of Australia (CSANZ/NHFA) 2018
- DOACs are also recommended for the treatment and long-term prevention of venous thromboembolism (VTE), with evidence suggesting they are at least as effective and as safe as conventional therapy (heparins and vitamin K antagonists)
In conclusion, while DOACs are recommended for certain conditions such as NVAF and VTE, their use for left ventricular thrombus is not currently supported by high-quality evidence and may be associated with an increased risk of SSE compared to warfarin. Therefore, warfarin remains the recommended anticoagulant for this condition according to current guidelines