DOAC vs. Warfarin for LV Thrombi

Apr 23, 2020
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Authors:
Robinson AA, Trankle CR, Eubanks G, et al.
Citation:
Off-Label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol 2020;Apr 22:[Epub ahead of print].
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • DOAC use is associated with higher rates of stroke and systemic embolism than warfarin for LV thrombi in a multicenter, retrospective analysis.
  • Prospective studies are needed to directly compare DOAC and warfarin therapy for LV thrombi.
  • Patients with documented resolution of LV thrombus by echo may still experience stroke or systemic embolism.

Study Questions:

What are the outcomes associated with direct oral anticoagulant (DOAC) versus warfarin use for patients with left ventricular (LV) thrombi?

Methods:

A three-center cohort study was performed, identifying 514 patients with LV thrombus on echocardiography between October 2013 and March 2019. Follow-up occurred through March 2019. Outcomes assessed included stroke or systemic embolism.

Results:

Of the 514 patients with LV thrombi, 300 received warfarin, while 185 received DOAC therapy. DOAC use was most commonly apixaban (141/185, 76.2%) or rivaroxaban (46/185, 24.9%). Median follow-up was 351 days (interquartile range, [IQR], 51-866 days). Among the 356 (69.3%) with follow-up imaging, this occurred after a median of 81 days (IQR, 19-185 days). Of the 231 patients with echocardiographic evidence of thrombus resolution, 20 (8.7%) developed a stroke or systemic embolism within 30 days after the echocardiogram study. After multivariable adjustment, anticoagulation with DOAC versus warfarin (adjusted hazard ratio [aHR], 2.64; 95% confidence interval [CI], 1.28-5.43) and prior stroke or systemic embolism (aHR, 2.07; 95% CI, 1.17-3.66) were associated with subsequent risk of stroke or systemic embolism.

Conclusions:

In this multicenter cohort study, use of DOAC to treat LV thrombus was associated with higher rates of stroke or systemic embolism than warfarin use.

Perspective:

While warfarin has been standard of care for management of LV thrombus, convenience of DOAC administration makes them an attractive alternative for many patients. This retrospective cohort study questions the efficacy of DOAC therapy as compared to warfarin. However, a few key questions remain: 1) How does length of therapy influence stroke or systemic embolism risk? 2) What dose of DOAC was given and might use of a ‘loading dose’ (similar to treatment of acute venous thromboembolism) reduce stroke or systemic embolism risk? 3) How reliable is a negative echocardiogram for determining when anticoagulation therapy can be discontinued? Each of these questions would be beneficial to study in a prospective trial.

Clinical Topics: Anticoagulation Management, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Anticoagulants, Diagnostic Imaging, Echocardiography, Embolism, Heart Failure, Off-Label Use, Secondary Prevention, Standard of Care, Stroke, Vascular Diseases, Venous Thromboembolism, Warfarin


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