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Antithrombotic Therapy for Patients With LV Mural Thrombus
Study Questions:
What is the effect of anticoagulation therapy on left ventricular (LV) thrombus evolution and complications?
Methods:
Between 2011 and 2018, the authors reviewed 90,065 consecutive echocardiogram reports to identify patients with confirmed LV thrombus. Major adverse cardiac events (MACE), including death, stroke, myocardial infarction, or acute peripheral artery embolism, were assessed, as were major bleeding and all-cause mortality.
Results:
The authors identified 159 patients with confirmed LV thrombus. These patients were treated with vitamin K antagonists (48.4%), parenteral heparin (27.7%), or direct oral anticoagulants (22.6%). Antiplatelet therapy was used in 67.9% of cases. The LV thrombus size was reduced in 121 (76.1%) cases with total resolution in 99 (62.3%) within a median of 103 days (interquartile range, 32-392 days). Predictors of LV thrombus improvement were nonischemic cardiomyopathy (hazard ratio [HR], 2.74; 95% confidence interval [CI], 1.43-5.26) and a smaller baseline thrombus area (HR, 0.66; 95% CI, 0.45-0.96). MACE occurred in 35.4% of patients with LV thrombus improvement and 40.0% of patients with persistent LV thrombus on imaging. MACE was less common in patients with baseline ejection fraction ≥35% (HR, 0.46; 95% CI, 0.23-0.93) and those with >3 months of anticoagulation (HR, 0.42; 95% CI, 0.20-0.88). Mortality was reduced in patients who experienced LV thrombus improvement (HR, 0.48; 95% CI, 0.23-0.98). Major bleeding occurred in fewer patients with LV thrombus improvement than those with persistent LV thrombus (9.1% vs. 25.0% for BARC ≥3 bleeding, HR, 0.34; 95% CI, 0.14-0.82).
Conclusions:
The authors concluded that the presence of LV thrombus was associated with a high risk of MACE and mortality, but that anticoagulation (especially >3 months) was associated with overall lower risk of MACE or all-cause mortality.
Perspective:
Management of LV thrombus has long been a challenge for many patients. Historically, an LV thrombus was a major complication of acute myocardial infarction. However, in the era of primary percutaneous coronary intervention, we now see LV thrombus from a variety of other conditions. This report of 159 consecutive cases of LV thrombus provides important prognostic and therapeutic information. First, the risk of adverse events is high. Second, anticoagulation can likely be achieved with a variety of agents, including direct oral anticoagulants. Third, patients should plan for ≥3 months of anticoagulation in most cases, with repeat imaging to assess for LV thrombus improvement/resolution.
Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Anticoagulation Management and ACS, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Acute Coronary Syndrome, Anticoagulants, Cardiomyopathies, Diagnostic Imaging, Echocardiography, Embolism, Fibrinolytic Agents, Heart Failure, Hemorrhage, Heparin, Myocardial Infarction, Platelet Aggregation Inhibitors, Secondary Prevention, Stroke, Stroke Volume, Thrombosis, Vitamin K
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