Is a DOAC a reasonable alternative to warfarin in the treatment of left ventricular thrombi?
My practice pattern has traditionally been yes based on case report data. Recently I heard from a colleague that warfarin is superior, so I delved into this literature. Long story short, it’s probably best to use warfarin as first line therapy, and to reserve a DOAC for those patients who can’t/won’t take warfarin – and if I were to use a DOAC, I would opt for apixaban or dagibatran given their BID dosing. There are no RCTs, but I’m attaching two articles that explored this same question with different results, as well as a systematic review. It’s worth reading through these Discussion sections for their various points about the underlying pathophysiology and drug mechanisms of action.
Kajy M, Shokr M, Ramappa P. Use of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus: Systematic Review of Current Literature. American journal of therapeutics. Published online 2019:10.1097/MJT.0000000000000937. doi:https://doi.org/10.1097/MJT.0000000000000937
Robinson AA, Trankle CR, Eubanks G, et al. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiology. 2020;5(6):685. doi:https://doi.org/10.1001/jamacardio.2020.0652
Willeford A, Zhu W, Stevens C, Thomas IC. Direct Oral Anticoagulants Versus Warfarin in the Treatment of Left Ventricular Thrombus. Annals of Pharmacotherapy. 2020;55(7):839-845. doi:https://doi.org/10.1177/1060028020975111
