NOACs vs Warfarin for LV Thrombus After Acute Myocardial Infarction

Sarfaroj Khan 

August 11, 2020

Takeaway

  • Novel oral anti-coagulants (NOACs) demonstrated improved left ventricular (LV) thrombus resolution post-acute myocardial infarction (AMI) compared with vitamin K antagonist (VKA).

  • Major bleeding events were lower with NOACs vs VKA (warfarin).

Why this matters

  • Current guidelines recommend the use of VKA for LV thrombus post-AMI.

  • However, based on evidence supporting non-inferiority of NOACs vs VKA for prevention of thromboembolic events in atrial fibrillation, NOACs are being increasingly used off licence for LV thrombus post-AMI.

  • Findings warrant randomised controlled trials to confirm this observational data.

Study design

  • An observational study of 2328 patients with AMI who underwent coronary angiography +/− percutaneous coronary intervention between 2015-2018.

  • Primary outcome: resolution of LV thrombus.

  • Secondary outcomes: bleeding events (defined by Bleeding Academic Research Consortium criteria) and thromboembolic events.

  • Funding: None disclosed.

Key results

  • Overall, 101 (4.3%) patients were diagnosed with LV thrombus.

  • Of 101 patients, 60 (59.4%) were treated with warfarin and 41 (40.6%) with NOAC therapy (rivaroxaban, 58.5%; apixaban, 36.5%; and edoxaban, 5%).

  • Overall rates of LV thrombus resolution were 86.1% over the follow-up period (median, 2.2 years).

  • NOAC vs VKA group had a greater and earlier LV thrombus resolution (82% vs 64.4% at 1 year; P=.0018), which persisted after adjusting for baseline variables (OR, 1.8; 95% CI, 1.2-2.9).

  • The incidence of major bleeding events was lower in the NOAC vs VKA group (0% vs 6.7%; P=.030), with no difference in rates of systemic thromboembolism (2.4% vs 5%; P=.388).

Limitations

  • Small sample size; non-randomised design.

  • Risk of residual confounding.

 

Jones DA, Wright P, Alizadeh MA, Fhadil S, Rathod KS, Guttmann O, Knight C, Timmis A, Baumbach A, Wragg A, Mathur A, Antoniou S. The Use of Novel Oral Anti-Coagulant's (NOAC) compared to Vitamin K Antagonists (Warfarin) in patients with Left Ventricular thrombus after Acute Myocardial Infarction (AMI). Eur Heart J Cardiovasc Pharmacother. 2020 Jul 30 [Epub ahead of print]. doi: 10.1093/ehjcvp/pvaa096. PMID: 32730627 View abstract. 

This clinical summary first appeared on Univadis, part of the Medscape Professional Network.

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