Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus.

INTRODUCTION To compare vitamin K antagonist (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death. AREAS COVERED Five observational studies were included (total n=700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; OR = 0.54, 95% CI= 0.29-1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR= 1.00, 95% CI = 0.58- 1.73, p = 0.99), bleeding (8.2% vs 4.4%;OR = 1.62, 95%CI = 0.69 to 3.77, p = 0.27) or death (12.7% vs. 11.8%; OR= 1.09, 95%CI = 0.59-2.0, p=0.79) were noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25 to 0.93, p = 0.03). EXPERT OPINION The current meta-analysis suggests a trend towards higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to remain the preferred management of LV thrombus with cautious off-label use of DOACs.