DOACs for LV Thrombus: The Experience from a Safety Net Hospital

An uncommon but potentially devastating complication of a cardiomyopathy is the formation of a left ventricular (LV) thrombus that embolizes and causes end-organ damage such as a stroke. Although there are no large, rigorous studies to guide care for LV thrombi, best clinical practice has been to treat patients with LV thrombi with anticoagulants. Traditionally, warfarin therapy was standard of care; however, that can be challenging for patients, requiring frequent blood tests and caution over numerous food and medication interactions. Direct oral anticoagulants (DOACs), while not FDA approved for the treatment of LV thrombi, are now used more commonly than warfarin for conditions such as atrial fibrillation. Previous studies involving the use of DOACs for the treatment of LV thrombi have had mixed results regarding their safety and efficacy; nevertheless, DOACs have several potential advantages in underserved communities with limited access to medical care – namely, fewer drug and diet interactions and lack of a need for routine drug level monitoring.

To assess the safety and efficacy of DOACs as currently used, we reviewed the medical records of all patients diagnosed with LV thrombi from Jan. 1, 2017, to June 30, 2018, and treated with DOACs at Parkland Health. As presented at #AHA21, our study cohort had more diversity (48% African American; 30% women) as compared with cohorts from prior studies addressing this issue. We found the average LV ejection fraction at diagnosis was 23 ± 13% and average treatment length was 16 ± 10 months. Twenty-two (76%) of 29 follow-up echocardiograms showed thrombus resolution. Thus, there was successful resolution of LV thrombus in most patients treated with DOACs. Further, we identified few adverse events.

Our data suggest that DOACs are an effective and safe therapy for LV thrombi, supporting their use for this purpose while we await larger randomized trials testing this strategy.