Direct oral anticoagulant use in left ventricular thrombus
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LETTER TO THE EDITOR
Open Access
Direct oral anticoagulant use in left ventricular thrombus Zafar Ali, Nicholas Isom, Tarun Dalia, Farhad Sami, Uzair Mahmood, Zubair Shah and Kamal Gupta* Abstract Left ventricular thrombus (LVT) is associated with a significant risk of ischemic stroke (IS) and peripheral embolization. Societal guidelines recommend the use of warfarin, with direct oral anticoagulants (DOACs) only for patients unable to tolerate warfarin. We studied the natural history of LVT with anticoagulation (AC) with emphasis on comparing warfarin and DOAC use. In this single center study, we identified patients with a confirmed LVT. Type and duration of anticoagulation, INR levels and clinical outcomes (bleeding, ischemic stroke or peripheral embolization, and thrombus resolution) were recorded. LVT was confirmed in a total of 110 patients. Mean age was 59 + 14 years. 79% were men. Underlying etiology was chronic ischemic cardiomyopathy in 58%, non-ischemic cardiomyopathy in 23%. AC was started in 96 (87%) patients. At 1 year follow up, 11 patients (10%) had a stroke while on any AC (2 had hemorrhagic stroke and 9 had IS). Of those with IS, 7 were on warfarin (71% of those had subtherapeutic INR) and 2 patients on DOACs had IS. The 1-year risk of any stroke was 15% in warfarin group (12% risk of ischemic stroke) compared to 6% in the DOACs group (p = 0.33). 37 (63%) patients on warfarin and 18 (53%) on DOACs had resolution of thrombus (p = 0.85). One-year risk of stroke with LVT is high (10%) even with AC. Most patients IS on warfarin had subtherapeutic INR. There was no statistical difference in stroke risk or rate of thrombus resolution between warfarin and DOACs treated patients. Keywords: Left ventricular thrombus, Warfarin, Direct oral anticoagulant, Cardiomyopathy Left ventricular thrombus (LVT) mostly occurs in patients with significant systolic dysfunction and can have devastating consequences from ischemic stroke (IS) and peripheral embolism. Risk factors associated with LVT formation are large anterior myocardial infarction, LV systolic dysfunction and severe wall motion abnormalities [1]. The incidence of LVT in the pre-percutaneous coronary intervention (PCI) era was reported to be as high as 40% but has decreased significantly (about 4%) in the primary PCI era [1, 2]. Various societal guidelines recommend 3 to 6 months of anticoagulation (AC) with warfarin (or up till thrombus resolution) [3–5]. However, there is a lack of good evidence to guide these recommendations. All guidelines recommend using vitamin * Correspondence: [email protected] University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City KS66160, USA
K antagonists. The 2014 stroke guidelines do suggest that direct oral anticoagulants (DAOCs) could be used in patients with warfarin intolerance, though there is very little data to support this use [4]. The goal of this study was to evaluate the natural history of LVT and incidence of thrombus resolution, with special emphasis on comparing warfarin and DOACs. In this single cent
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