Do post-MI patients with a left ventricular aneursym need to remain on lifelong anticoagulation?
This particular clinic patient did have a left ventricular thrombus which has now resolved; the aneurysm remains.
The 2013 AHA/ACC STEMI guidelines are IIb, LOE C for anticoagulating patients with "anterior apical akinesis or dykinesis." I found this pretty nice study done in Korea which looked at patients with left ventricular aneurysms thought to be ischemic in etiology, who were followed for a little over three years on average, on or off warfarin. The primary outcome was a composite of death, nonfatal MI, CVA, and systemic embolization. They did not find any difference between the two groups:
Figure 2.
Interestingly, subgroup analysis in this study did not show any clear benefit to anticoagulation even in patients who had a left ventricular thrombus:
Figure 3.
But, we should we wary of drawing conclusions from subgroup analysis of an observational study. Patients with left ventricular thrombus were more likely to have stroke/systemic embolism than those without, unsurprisingly, though it's worth reading the whole Discussion section which touches on how the data for anticoagulating LV thrombus is not as robust as we might have imagined.
At any rate, I found this data somewhat helpful in considering the decision to stop A/C in this patient who does not have another indication. This study is limited: it's single-center, small, done outside the US, and observational - the patients who ended up on warfarin were arguably sicker (more afib, lower EFs, greater thrombus burden) than those who did not. I also have concerns about comparing management of MIs from the mid-1990s to around 2010, and I did not think the issue of antiplatelet therapy was adequately explored. Additionally, I would imagine that the geometry of an aneurysm also factors into its thrombus/embolus risk. Finally, let's not forget that this data only applies to post-MI patients, and that it may or may not be extrapolated to other etiologies of left ventricular aneurysms (HCM, Tako-tsubo's, Chagas, etc.).
Ultimately I believe this data is not good enough to be conclusive, and that we'll need to engage in some shared decision making at the next clinic visit to determine our final care plan for this patient. I am very interested to hear about any experience you might have with this clinical scenario, too!
Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. Journal of the American College of Cardiology. 2011;57(8):e16-e94. doi:https://doi.org/10.1016/j.jacc.2010.11.006
Lee GY, Song YB, Hahn JY, et al. Anticoagulation in Ischemic Left Ventricular Aneurysm. Mayo Clinic Proceedings. 2015;90(4):441-449. doi:https://doi.org/10.1016/j.mayocp.2014.12.025
