Prevention of Left Ventricular Thrombus Formation and Systemic Embolism After Anterior Myocardial Infarction: A Systematic Literature Review

Incidence of left ventricular thrombus following STEMI in the modern era via multimodality imaging: A systematic review and meta-analysis

Background

Left ventricular thrombus (LVT) is a significant complication in STEMI. Previous studies were conducted prior to modern timely percutaneous reperfusion networks. Current expert opinion suggests incidence in the current era has decreased. We conducted a systematic review and meta-analysis to better understand the incidence and diagnosis of LVT in patients with STEMI treated with timely percutaneous techniques as assessed by multimodality imaging.

Methods

Cochrane, EMBASE, LILACS, and MEDLINE were searched over the last 10 years only including studies using contemporary techniques. The primary outcome was detection of LVT in patients via echocardiogram with or without contrast or Cardiac MRI (cMRI) following STEMI (both anterior and any territory) treated with PCI. Data was pooled across studies and statistical analysis was conducted via random effects model.

Results

31 studies were included. 18 studies included data on any territory STEMI, totaling 14,172 patients, and an incidence of 5.6% [95% CI 4.3-7.0]. 18 studies were included in analysis for anterior STEMI, totaling 7382 patients and incidence of 12.7% [95% CI 9.8-15.6]. Relative to cMRI as a gold standard, the sensitivity of non-contrast echocardiography to detect LVT was 58.2% [95% CI 46.6-69.2] with a specificity of 97.8% [95% CI 96.3-98.8].

Conclusions

Incidence of LVT in STEMI patients treated with contemporary timely percutaneous revascularization is in keeping with historical data and remains significant, suggesting this remains an ongoing issue for further investigation. Numerically, both cMRI and contrast echo detected more LVT compared to non-contrast echo in any-territory STEMI patients.

Prophylactic Anticoagulation to Prevent Left Ventricular Thrombus Following Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Clinical practice guidelines from the American Heart Association recommend consideration of prophylactic anticoagulation to prevent left ventricular thrombus (LVT) formation in patients with anterior ST-elevation myocardial infarction. These guidelines were given a low certainty of evidence (class IIb, level C), relying primarily on case studies and expert consensus to inform practice. Our objective was to compare the safety and efficacy of prophylactic anticoagulation, in addition to dual antiplatelet therapy, in the current era of timely primary percutaneous coronary intervention. Electronic databases, including EMBASE, MEDLINE, and Cochrane Library, were systematically searched from January 2012 through June 2022. A total of 7,378 publications were screened, and 5 publications were eventually included in this review: 1 randomized control trial and 4 retrospective studies involving 1,461 patients. Data were pooled using a fixed-effects model and reported as odds ratios (ORs) with 95% confidence intervals (CIs). The primary outcome of interest was the rate of LVT formation, and the secondary outcomes were the rate of major bleeding and systemic embolism. Pooled analysis showed a significantly lower rate of LVT formation (OR 0.28, 95% CI 0.11 to 0.73, p <0.01) and significantly higher rates of bleeding (OR 2.85, 95% CI 1.13 to 7.24, p = 0.03) in the triple therapy group compared with dual antiplatelet therapy. No significant difference was observed in the rate of systemic embolism between the groups (OR 0.37, 95% CI 0.12 to 1.13, p = 0.08). In this meta-analysis, there is no conclusive evidence to either support or oppose the use of triple therapy for LVT prevention in patients with anterior ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Appropriately powered randomized controlled trials are warranted to further evaluate the benefits of LVT prevention against the risks of major bleeding in this population.

Antithrombotic Management and Outcomes of Anterior ST-Elevation Myocardial Infarction With New-Onset Wall Motion Abnormalities in Men and Women

Background

In patients with anterior ST-elevation myocardial infarction (STEMI) and new-onset antero-apical wall motion abnormalities (WMAs), whether the rate of prophylaxis against left ventricular thrombus and outcomes differ between men and women is unknown.

Methods

A multicentre retrospective cohort study of patients with STEMI and new-onset antero-apical WMAs treated with primary percutaneous coronary intervention was conducted. Patients with an established indication of oral anticoagulation (OAC) were excluded. The rates of triple therapy (double antiplatelet therapy + OAC) at discharge were compared for women vs men. The rates of net adverse clinical events, a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at 6 months were compared across sex using a multivariate logistic regression model.

Results

A total of 1664 patients were included in the primary analysis, of whom 402 (24.2%) were women and 1262 (75.8%) were men. A total of 138 women (34.3%) and 489 men (38.7%) received a triple therapy prescription at discharge (P = 0.11). At 6 months, 33 women (8.2%) and 96 men (7.6%) experienced a net adverse clinical event (adjusted odds ratio 0.82; 95% confidence interval 0.49-1.37). No difference occurred in the risk of bleeding events and ischemic events between men and women, when these were analyzed separately.

Conclusions

The rates of OAC prescription for left ventricular thrombus prophylaxis and clinical outcomes at 6 months were similar in women and men following anterior STEMI with new-onset antero-apical WMAs.

Contemporary incidence and predictors of left ventricular thrombus in patients with anterior acute myocardial infarction

BACKGROUND

The incidence of left ventricular thrombus (LVT) after anterior acute myocardial infarction (AMI) has not been well established in the era of primary percutaneous coronary intervention (pPCI) and potent dual antiplatelet therapy. The objective of this study is to establish the contemporary incidence of LVT in this population, to identify their risk factors, and to examine their association with clinical outcomes.

METHODS

A multicenter retrospective cohort study including AMI patients with new-onset antero-apical wall motion abnormalities treated with pPCI between 2009 and 2017 was conducted. The primary outcome was LVT during the index hospitalization. Predictors of LVT were identified using multivariate logistic regression. Net adverse clinical events (NACE), a composite of mortality, myocardial infarction, stroke or transient ischemic attack, systemic thromboembolism or BARC type 3 or 5 bleeding at 6 months were compared between the LVT and no LVT groups.

RESULTS

Among the 2136 patients included, 83 (3.9%) patients developed a LVT during index hospitalization. A lower left ventricular ejection fraction (LVEF) [adjusted odds ratio (aOR) 0.97; 95% confidence intervals (CI) 0.94-0.99] and the degree of worse anterior WMA (aOR 4.34; 95% CI 2.24-8.40) were independent predictors of LVT. A NACE occurred in 5 (5.72 per 100 patient-year) patients in the LVT group and in 127 (6.71 per 100 patient-year) patients in the no LVT group at 6 months [adjusted hazard ratio (aHR): 0.87; 95% CI 0.35-2.14].

CONCLUSIONS

The risk of LVT after anterior AMI with new-onset wall motion abnormalities is low, but this complication remains present in the contemporary era of timely pPCI and potent dual antiplatelet therapy .

Case report: Oral anticoagulant combined with percutaneous coronary intervention for peripheral embolization of left ventricular thrombus caused by myocardial infarction in a patient with diabetes mellitus

Background

Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction (MI) in patients with diabetes. An embolic complication caused by LVT is a key clinical problem and is associated with worsened long-term survival.

Case presentation

A 45-year-old man with persistent left abdominal pain for 1 week and left leg fatigue was admitted to the emergency department. The cause of abdominal pain was embolism of the renal artery, the splenic artery, and the superior mesenteric artery caused by cardiogenic thrombosis, which further led to splenic infarction and renal infarction. It was unclear when MI occurred because the patient had no typical critical chest pain, which may have been related to diabetic complications, such as diabetic peripheral neuropathy. Diabetes plays a pivotal role in MI and LVT formation. Because coronary angiography suggested triple vessel disease, percutaneous transluminal coronary angioplasty (PTCA) was conducted, and two drug-eluting stents were placed in the left anterior descending coronary artery (LAD). Due to a lack of randomized clinical control trials, the therapy of LVT and associated embolization has been actively debated. According to the present guidelines, this patient was treated with low-molecular-weight heparin and warfarin (oral anticoagulants) for 3 months in addition to aspirin (100 mg/day) and clopidogrel (75 mg/day) for 1 year. No serious bleeding complications were noted, and a follow-up examination showed no thrombus in the left ventricle or further peripheral thrombotic events.

Conclusion

Peripheral embolization of LVT caused by MI leading to multiple organ embolization remains a rare occurrence. Diabetes plays a pivotal role in MI and LVT formation. Successful revascularization of the infarct-related coronary artery and anticoagulation therapy is important to minimize myocardial damage and prevent LVT. The present case will help clinicians recognize and manage LVT in patients with diabetes and related peripheral arterial thrombotic events with anticoagulation.

Risk factors for in-hospital systemic thromboembolism in myocardial infarction patients with left-ventricular thrombus: A multicenter retrospective study

Left-ventricular thrombus (LVT) is a potentially life-threatening disease. However, few studies have explored the risk factors of in-hospital systemic thromboembolism (ST) in LVT patients. In this multicenter retrospective study, we enrolled myocardial infarction patients with LVT from January 2008 to September 2021. Multivariable logistic regression analysis was applied to identify the independent risk factors for ST in LVT patients. A total number of 160 hospitalized LVT patients [median follow-up period 50 months (18.3-82.5 months)] were subjected to analysis. Of them, 54 (33.8%) patients developed acute myocardial infarction, 16 (10%) had ST, and 33 (20.6%) died. Comparable baseline characteristics were established between the ST and non-ST groups, except for the heart failure classification (P = .014). We obtained the following results from our multivariable analysis, based on the use of HFrEF as a reference: HFpEF [odd ratio (OR), 6.2; 95% confidence interval (CI), 1.4-26.3; P = .014] and HFmrEF (OR, 5.0; 95%CI, 1.1-22.2; P = .033). In conclusion, HFpEF, and HFmrEF may be independent risk factors for in-hospital ST development.

Exceptional Presentation of Heart Thrombi Secondary to Myocardial Infarction Due to COVID-19 Pandemic

Left ventricular thrombi (LVT) is an uncommon complication that can occur after a myocardial infarction thanks to the discovery of revascularization therapies. Before it, an LVT was described in up to 60% of patients with myocardial infarction. The authors present a case of a 46-year-old female who presented to the emergency department with one week of dyspnea, who had symptoms of chest pain for a week, however, did not show up in the hospital due to the ongoing COVID-19 pandemic. In-patient new-onset heart failure workup during that time was minimized due to the state of emergency COVID-19 pandemic. The patient lost to follow up appointment and then presented again to the hospital with Echocardiogram at that time showing mid to distal septal and apical hypokinesis, EF 30%-35% and a highly mobile circumferential echogenic mass of 2.4x2.4 cm noted in the left ventricle (LV) with differentials of LV thrombus vs cardiac tumor. Hospital complicated by LV thrombus embolization with bilateral lower extremities (LEs) arterial thrombi and limb ischemia. Left cardiac cath with a result of severe triple vessel disease requires either coronary artery bypass grafting (CABG) or complex percutaneous coronary intervention (PCI). A tentative plan was to pursue CABG, however, lower extremities must be healed prior to cardiothoracic surgery.

Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement

OBJECTIVES

Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.

Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention

The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.

Comparison of Left Ventricular Global Strain in Anterior and Non-anterior Wall Myocardial Infarction With CMR Tissue Tracking

Left ventricular (LV) myocardial dysfunction occurs after myocardial infarction (MI) is associated with the location, infarct size, and transmurality degrees of MI. The myocardial strain is a sensitive index used for the quantification of myocardium dysfunction. This study used Tissue-Tracking to evaluate whether the different location of MI would result in different myocardial dysfunction. One hundred patients diagnosed with MI who underwent cardiovascular magnetic resonance examination were included. The tissue-tracking indices, LV global radial strain (GRS), global circumferential strain (GCS), global longitudinal strain (GLS), and the infarct size (IS,% of LV mass) were quantified. There were 42 cases of anterior wall MI (AWMI) and 58 cases of non-anterior wall MI (NAWMI). The GCS of AWMI was significantly lower than that of NAWMI (P = 0.036). In the same level of infarct size, the myocardial strain of AWMI was not significantly different from NAWMI group (P > 0.05). The GRS and GCS were significantly different between transmurality > 50% group with transmurality ≤ 50% group (P < 0.05). The present study demonstrated that LV MI is associated with reduced myocardial strain, and the infarct size and degrees of transmurality were both related to the decline of myocardial strain in patients with MI.

Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

Anticoagulation in the cardiac patient: A concise review

Anticoagulation has multiple roles in the treatment of cardiovascular disease, including in management of acute myocardial infarction, during percutaneous coronary intervention, as stroke prophylaxis in patients with atrial arrhythmias, and in patients with mechanical heart valves. Clinical anticoagulation choices in the aforementioned diseases vary widely, due to conflicting data to support established agents and the rapid evolution of evidence-based practice that parallels more widespread use of novel oral anticoagulants. This review concisely summarizes evidence-based guidelines for anticoagulant use in cardiovascular disease, and highlights new data specific to direct oral anticoagulants.