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Badescu MC, Sorodoc V, Lionte C, Ouatu A, Haliga RE, Costache AD, Buliga-Finis ON, Simon I, Sorodoc L, Costache II, Rezus C. Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus. J Pers Med 2023; 13:jpm13010158. [PMID: 36675819 PMCID: PMC9866081 DOI: 10.3390/jpm13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/17/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Victorita Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Catalina Lionte
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ioan Simon
- Department of Surgery, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laurentiu Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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Honan KA, Jogimahanti A, Khair T. An Updated Review of the Efficacy and Safety of Direct Oral Anticoagulants in Treatment of Left Ventricular Thrombus. Am J Med 2022; 135:17-23. [PMID: 34469758 DOI: 10.1016/j.amjmed.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022]
Abstract
Left ventricular (LV) thrombus is a potentially serious complication affecting males and females with ischemic and nonischemic cardiomyopathy-specifically, after acute myocardial infarctions of the anterior left ventricular wall and long-standing tachyarrhythmias, respectively. LV thrombi pose significant risks for systemic embolization and devastating stroke events, while also demanding a treatment carrying inherent risks of its own. It is therefore imperative to have accurate detection of these ventricular thrombi and an appropriate understanding of the risks and benefits regarding management. Anticoagulation using warfarin has long been established as the gold-standard level of care in the current guidelines of the American College of Cardiology but the advent of direct oral anticoagulants (DOACs) prompts a re-examination of the literature. The particular question we seek to answer lies in the efficacy of these drugs and the safety and outcomes when used to treat LV thrombi. Recent case reports, meta-analyses, and most recently, the breakthrough of 2 novel randomized controlled trials have shown DOACs to be a promising treatment for LV thrombus. Contrarily, some retrospective cohort reviews suggest less-than-promising outcomes. This meta-analysis hopes to provide a current, curated review of up-to-date safety and efficacy in the documented tales of DOACs and LV thrombi that has been published since early 2020-by selecting these curated case studies, and analyzing the most recent randomized controlled trials, we hope to engage the reader with clearer illustrations of the key components of both the advocacy and warning of this pharmaceutical intervention.
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Affiliation(s)
- Kevin A Honan
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston.
| | - Arjun Jogimahanti
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
| | - Tarif Khair
- University of Texas Health Science Center at Houston/McGovern Medical School, Houston
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1161] [Impact Index Per Article: 387.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Raza N, Burnette S, Joolhar FS, Ghandforoush A, Win TT. A Giant Left Intraventricular Thrombus Associated With Apical Hypertrophic Cardiomyopathy Mimics Cancer. Cureus 2021; 13:e15554. [PMID: 34123682 PMCID: PMC8189833 DOI: 10.7759/cureus.15554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a common disease that can be acquired due to chronic hypertension or via autosomal dominant inheritance. Several patterns of HCM have been described, of which a rare variant is apical hypertrophic cardiomyopathy (AHCM). Atrial thrombus is a well-recognized complication of HCM especially in the setting of atrial fibrillation (AF). However, left ventricular thrombus (LVT) formation is not nearly as prevalent as atrial thrombus. Here is a case of a 57-year-old Hispanic female with AHCM who presented with significant unintentional weight loss and unexplained anemia and was subsequently found to have a large left intraventricular mass suspicious for a tumor vs. ventricular thrombus. The diagnosis was complicated due to the large size of the mass and presenting symptoms suspicious of malignancy.
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Affiliation(s)
- Nadia Raza
- Internal Medicine, University of California, Los Angeles (UCLA) Kern Medical Center, Bakersfield, USA
| | - Shane Burnette
- Internal Medicine/Cardiology, Kern Medical Center, Bakersfield, USA
| | - Fowrooz S Joolhar
- Cardiology, University of California, Los Angeles (UCLA) Kern Medical Center, Bakersfield, USA
| | - Aslan Ghandforoush
- Cardiology, University of California, Los Angeles (UCLA) Kern Medical Center, Bakersfield, USA
| | - Theingi Tiffany Win
- Cardiology, University of California, Los Angeles (UCLA) Kern Medical Center, Bakersfield, USA
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Chen R, Wang Y, Yang J, Cheng X, Wang J, Huang L. Recurrent pheochromocytoma with catecholamine cardiomyopathy and left ventricular thrombus: a case report. J Int Med Res 2021; 49:3000605211007723. [PMID: 33884914 PMCID: PMC8074535 DOI: 10.1177/03000605211007723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pheochromocytoma is a rare and usually benign tumor of the adrenal glands. We report a case of a 40-year-old woman with recurrent pheochromocytoma and catecholamine cardiomyopathy. She had no history of other types of tumors or connective tissue disease. She had already undergone surgery twice to remove the pheochromocytoma, which had now recurred for the second time. A thrombus in the left ventricle was also noted upon imaging examination, which dissipated after anticoagulation therapy using dabigatran, allowing the patient to opt for an elective third surgery. This paper describes the clinical outcome of using the anticoagulant dabigatran to treat left ventricular thrombosis in this rare case of recurrent pheochromocytoma, and thus further contributing to the knowledge of the clinical management of this rare and complicated disease.
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Affiliation(s)
- Renzheng Chen
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yong Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaofeng Cheng
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiang Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lan Huang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Mir T, Sattar Y, Attique HB, Hussain T, Alraies MC, Sheikh M, Qureshi WT. Meta-analysis of direct oral anticoagulants compared with vitamin K antagonist for left ventricle thrombus. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 35:141-146. [PMID: 33722539 DOI: 10.1016/j.carrev.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The use of direct oral anticoagulants (DOAC) in preference to vitamin K antagonists (VKA) as a treatment of left ventricle (LV) thrombus is controversial. METHODS Literature search for full-text articles and conference abstracts was performed using PubMed, EMBASE databases search was performed to identify articles that compared use of DOAC vs. VKA in patients with LV thrombus. The primary outcome was composite failure or adverse effects of DOAC and VKA. Other outcomes were resolution of thrombus, systemic thromboembolism, major bleeding, and mortality. Pooled odds ratio (OR) with 95% confidence interval (CI) were computed using random effects model. RESULTS Seven studies with 1003 patients (mean age DOAC = 58.8 years and VKA = 58.9 year, 55.5% males) were included in this study. There were 306 (30.5%) patients that were treated with DOAC and 697 (69.5%) patients were treated with VKA. Overall, there were no significant differences between both agents in terms of composite failure/adverse effects, resolution of thrombus, systemic embolism, major bleeding, or mortality. CONCLUSION In this pooled analysis, outcomes in patients on DOAC were comparable to VKA. The hypothesis generated could suggest DOAC could be used interchangeably with VKA in patients with LV thrombus. Randomized trials are needed for generalization of results.
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Affiliation(s)
- Tanveer Mir
- Internal Medicine, Detroit Medical Center, Wayne State University. Detroit, MI, USA
| | - Yasar Sattar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Tanveer Hussain
- Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - M Chadi Alraies
- Cardiovascular Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Mujeeb Sheikh
- Interventional Cardiology, Promedica Toledo Hospital, OH, USA
| | - Waqas T Qureshi
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA.
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Sedhom R, Abdelmaseeh P, Megaly M, Asinger R. Use of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombi: A Systematic Review. Am J Med 2020; 133:1266-1273.e6. [PMID: 32565258 DOI: 10.1016/j.amjmed.2020.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Abstract
The off-label use of direct oral anticoagulants (DOACs) for the treatment of left ventricular thrombi has grown over the past several years given the ease of administration, absence of a requirement for international normalized ratio (INR) monitoring, and freedom from dietary restrictions; however, the evidence for their safety and efficacy is contradictory. We systematically searched PubMed and Google Scholar from January 1, 2009, to April 25, 2020, for studies of DOACs for treatment of left ventricular thrombi. Fifty-three articles (of 1,168 patients) met our inclusion criteria. We found that the studies have reached conflicting results; based on our findings, their routine use for the treatment of left ventricular thrombi cannot be recommended. Adequately powered randomized controlled trials are needed to determine the safest and most effective treatment for left ventricular thrombi.
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Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Penn.
| | - Peter Abdelmaseeh
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Penn
| | - Michael Megaly
- Department of Cardiology, Hennepin Healthcare, Minneapolis, Minn; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis
| | - Richard Asinger
- Department of Cardiology, Hennepin Healthcare, Minneapolis, Minn
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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 anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:398-404. [PMID: 32730627 DOI: 10.1093/ehjcvp/pvaa096] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/08/2020] [Accepted: 07/23/2020] [Indexed: 12/23/2022]
Abstract
Abstract
Aim
Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI.
Methods and results
This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388).
Conclusion
These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.
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Affiliation(s)
- Daniel A Jones
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Momin A Alizadeh
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Krishnaraj S Rathod
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Oliver Guttmann
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Charles Knight
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Adam Timmis
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Andreas Baumbach
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Andrew Wragg
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Anthony Mathur
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
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Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus—A New Indication? A Meta-summary of Case Reports. J Cardiovasc Pharmacol 2020; 75:530-534. [DOI: 10.1097/fjc.0000000000000826] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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10
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Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists. Clin Drug Investig 2020; 40:343-353. [DOI: 10.1007/s40261-020-00898-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Verma B, Singh A, Kumar M. Use of dabigatran for treatment of left ventricular thrombus: A tertiary care center experience. J Family Med Prim Care 2019; 8:2656-2660. [PMID: 31548950 PMCID: PMC6753807 DOI: 10.4103/jfmpc.jfmpc_459_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/19/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Direct oral anticoagulants (DOACs) are now replacing vitamin K oral anticoagulants (VKAs) owing to superior efficacy, rapid action, less bleeding, wider therapeutic range,and fewer food and drug interactions.Unfortunately, the available data on the use of DOACs, particularly dabigatran, for treatment of left ventricular thrombus (LVT) issparse. We have hereby presented the largest study on use of dabigatran in LVT. METHODS Retrospective data of patients having LVT as diagnosed by transthoracic echocardiography (TTE) was screened. Patients on dabigatran were included in the study and follow up data of 6 months was obtained through medical records. RESULTS Of the 15 patients included in the study, the most frequent etiology was ischemic heart disease (67%), including 7 patients of STEMI (47%), followed by non-ischemic cardiomyopathy in 5 patients (33%). Only one patient, with STEMI, developed mild gastrointestinal bleeding at 3 months. Complete clot resolution was seen in 2 patients (13%) at first week of follow up and total 5 patients (33%) at the end of second week. The rate of clot resolution at 1 month, 3 months, and 6 months were 80%, 93% and 100%, respectively. The median duration required for complete clot resolution was 30 days (IQR=14-30). CONCLUSION Dabigatran appears to be safe, highly efficacious and results in rapid LV clot resolution. DOACs may be a suitable alternative to warfarin in treatment of LV thrombus. However, larger studies are required to validate this hypothesis.
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Affiliation(s)
- Bhupendra Verma
- Department of Cardiology, Ujala Hospital, Kashipur, U S Nagar, UK, India
| | - Amrita Singh
- Department of Cardiology, Ujala Hospital, Kashipur, U S Nagar, UK, India
| | - Manu Kumar
- Department of Cardiology, Ujala Hospital, Kashipur, U S Nagar, UK, India
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12
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Bahmaid RA, Ammar S, Al-Subaie S, Soofi MA, Mhish H, Yahia MA. Efficacy of direct oral anticoagulants on the resolution of left ventricular thrombus-A case series and literature review. JRSM Cardiovasc Dis 2019; 8:2048004019839548. [PMID: 31007906 PMCID: PMC6456843 DOI: 10.1177/2048004019839548] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/17/2019] [Accepted: 02/28/2019] [Indexed: 11/16/2022] Open
Abstract
Background Left ventricular thrombus is a frequent complication of acute myocardial infarction and a risk factor for thromboembolic complications. Warfarin has been frequently used, but has some disadvantages that limit its use. Direct oral anticoagulants, in particular Dabigatran and Rivaroxaban have been proved to be effective in preventing thromboembolism among patients with non-valvular atrial fibrillation. However, no randomized clinical trials testing the efficacy and safety of these agents in patients with existing left ventricular thrombus. Furthermore, direct oral anticoagulants are still not approved by the Food and Drug Administration in the management of left ventricular thrombus. Method This study was a retrospective cohort assessing the efficacy of direct oral anticoagulants (Dabigatran or Rivaroxaban) on the resolution of left ventricular thrombus in patients taking either of these drugs during the study period from December, 2011 to December, 2016 at King Fahad Medical City. All patients’ records were reviewed and all patients who were diagnosed with left ventricular thrombus were included. Patients without available echocardiogram records were excluded. The study was approved by the institutional review board of King Fahad medical city, Riyadh Saudi Arabia. Result During the defined study period we found that 413 and 1218 patients were taking Dabigatran and Rivaroxaban, respectively. After filtering them based on the specialty of the prescriber, we ended up with 299 patients who have been started on Dabigatran and 448 patients who have been started on Rivaroxaban by cardiologists. Moreover, after reviewing echocardiogram reports for all of them (747 patients), we found that 11 patients were diagnosed to have left ventricular thrombus. Among those 11 patients, seven of them were treated with direct oral anticoagulants from the beginning and the remaining four patients were shifted from Warfarin to direct oral anticoagulants. All of them (7 patients) showed left ventricular thrombus resolution on follow-up echocardiogram. Conclusion Use of direct oral anticoagulants showed promising results in the resolution of left ventricular thrombus in patients diagnosed with left ventricular thrombus. Further studies at multiple health care centers are needed to further evaluate the efficacy and safety of direct oral anticoagulants as compared to traditional treatment in patients with left ventricular thrombus.
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14
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Non-vitamin K antagonist oral anticoagulants for the treatment of intracardiac thrombosis. J Thromb Thrombolysis 2018; 46:332-338. [DOI: 10.1007/s11239-018-1693-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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15
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Noflatscher M, Moes N, Gassner EM, Marschang P. Dabigatran Added to Dual Antiplatelet Therapy to Treat a Left Ventricular Thrombus in an 87 Year Old Patient With Myocardial Infarction and Very High Bleeding Risk. Front Pharmacol 2018; 9:217. [PMID: 29670522 PMCID: PMC5893831 DOI: 10.3389/fphar.2018.00217] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 02/27/2018] [Indexed: 01/08/2023] Open
Abstract
Background: A left ventricular (LV) thrombus is detected in approximately 5-10% of patients after myocardial infarction (MI). If left untreated, these LV thrombi carry a significant risk of complications including embolic stroke. According to current guidelines, anticoagulation with vitamin K antagonists (VKA) is recommended to treat a LV thrombus. Case presentation: An 87 year old patient was referred to our department with non ST-elevation MI. Five months before, he had been diagnosed with a subacute ST elevation MI, which had been treated conservatively. Recently, a rectal neoplasia had been diagnosed, but not operated yet. The patient underwent coronary angiography with implantation of two drug eluting stents (Cre8) requiring dual antiplatelet therapy. During ventriculography an apical LV thrombus of 16 mm diameter was detected. Due to the high bleeding risk in this patient, VKA therapy with potentially fluctuating international normalized ratio (INR) values was considered unsuitable. Therefore, dabigatran at a dose of 110 mg bid was chosen as anticoagulation therapy. After 4 weeks, cardiac computed tomography was performed, which failed to detect the LV thrombus described previously. Notably, triple therapy with dabigatran, clopidogrel, and aspirin was well tolerated without evidence for bleeding. The surgical resection of the rectal neoplasm was performed 2 months later without bleeding complications. Discussion: Anticoagulation is effective in patients with MI and a LV thrombus in reducing the risk of embolization and in dissolving the thrombus. Our case is complex due to the required triple therapy, very old age and significant bleeding risk of our patient due to the rectal neoplasia. Although only few reports are available for the use of non VKA oral anticoagulants (NOAC) in this indication, we chose dabigatran at a dose of 110 mg bid added to dual antiplatelet therapy for our patient. Besides the advantage of a predictable pharmacokinetic profile of NOAC in contrast to VKA, the effect of dabigatran can rapidly be reversed by idaruzicumab in the case of severe bleeding. Conclusion remarks: Physicians should carefully weigh the risk of thromboembolic events versus the risk of bleeding when combining antiplatelet with anticoagulation therapy.
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Affiliation(s)
- Maria Noflatscher
- Angiology, Department of Internal Medicine III Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Nicolas Moes
- Angiology, Department of Internal Medicine III Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Eva-Maria Gassner
- Department of Radiology, Innsbruck Medical University, Innsbruck, Austria
| | - Peter Marschang
- Angiology, Department of Internal Medicine III Cardiology, Innsbruck Medical University, Innsbruck, Austria
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Santoro F, Stiermaier T, Tarantino N, De Gennaro L, Moeller C, Guastafierro F, Marchetti MF, Montisci R, Carapelle E, Graf T, Caldarola P, Thiele H, Di Biase M, Brunetti ND, Eitel I. Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry. J Am Heart Assoc 2017; 6:JAHA.117.006990. [PMID: 29203578 PMCID: PMC5779019 DOI: 10.1161/jaha.117.006990] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Left ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome. Methods and Results We enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99). Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.
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Affiliation(s)
- Francesco Santoro
- Department of Medical and Surgery Science, University of Foggia, Italy.,AsklepiosKlinik - St Georg, Hamburg, Germany
| | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Nicola Tarantino
- Department of Medical and Surgery Science, University of Foggia, Italy
| | | | - Christian Moeller
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | | | | | - Elena Carapelle
- Department of Medical and Surgery Science, University of Foggia, Italy
| | - Tobias Graf
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Holger Thiele
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Matteo Di Biase
- Department of Medical and Surgery Science, University of Foggia, Italy
| | | | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
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Orenes-Piñero E, Esteve-Pastor MA, Valdés M, Lip GY, Marín F. Efficacy of non-vitamin-K antagonist oral anticoagulants for intracardiac thrombi resolution in nonvalvular atrial fibrillation. Drug Discov Today 2017; 22:1565-1571. [DOI: 10.1016/j.drudis.2017.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 02/02/2023]
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Abstract
Left ventricular thrombus (LVT) complicates both ischemic and non-ischemic cardiomyopathies and is a potential cause of thromboembolic complications such as stroke. Management of LVT in the 21st century is primarily based on studies before the widespread use of potent pharmacological and interventional therapies such as primary percutaneous coronary intervention, especially in the setting of acute myocardial infarction. Though advances in diagnostic technology have improved detection of LVT, clinicians face several uncertainties in the management of LVT in daily practice. The aim of this paper is to examine several controversies in the diagnosis and management of LVT. Prospective studies are needed to advance therapy of LVT.
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Affiliation(s)
- Fuad Habash
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Division of Cardiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, slot 532, Little Rock, AR 72205, USA
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