Direct Oral Anticoagulants Versus Vitamin K Antagonists for Left Ventricular Thrombus

A Systematic Review and Meta-analysis

Eric Pasqualotto,¹ Douglas Mesadri Gewehr, MD,²*³ Rafael Oliva Morgado Ferreira,¹ Caroliny Hellen Azevedo da Silva,⁴ Jhonny Wilson Limachi Choque,⁵*⁶ Sara Almeida Cruz,⁷ Amanda Park,⁸ Luiz Fernando Kubrusly, PhD²*³*⁹
¹Federal University of Santa Catarina, Florianópolis, Brazil. ²Denton Cooley Institute of Research, Science and Technology, Curitiba, Brazil. ³Curitiba Heart Institute, Curitiba, Brazil. ⁴Federal University of Rio Grande do Norte, Natal, Brazil. ⁵University of San Simón, Cochabamba, Bolivia. ⁶Epidemiology Unit,
Military Social Security Corporation, Cochabamba, Bolivia. ⁷Immanuel Kant Baltic Federal University, Kaliningrad, Kaliningrad Oblast, Russia. ⁸Faculty of Medical Sciences of Santos, Lusíadas University Center
⁹Mackenzie Evangelical College of Paraná, Curitiba, Paraná, Brazil

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Data sources Study design Systematic review, meta-analysis, and subgroup analyses
Cochrane 4 randomized and 29 non-randomized

4,450 patients Mean age: 49.6 - 69 years old

Mantel-Haenszel REML random-effects with Odds-Ratio (OR)
Population with left ventricle Sex: 49.6% Male Statistical Analysis
and 95% Confidence Intervals (CI)
thrombus Follow-up: 3 months - 3 years

DOACs Risk of Bias Low-risk 14%

Rob 2 tool Some concerns 75% ROBINS-I tool
Moderate-risk 34%

1,332
by study design Randomized No information 25% Non-randomized No information 52%
Comparison VKA
3,118

Endpoints Overall Rivaroxabana Apixabana

Safety Endpoints
Odds Ratio 95% CI
Favors DOACs Favors VKA
0 1 5
Odds Ratio 95% CI
Efficacy Endpoints Favors DOACs Favors VKA 895 2,318 0.72 (0.55 - 0.96)
0 1 5 Any Bleeding 170 144 1.11 (0.45 - 2.72)
1,223 2,935 0.90 (0.65 - 1.26)
Stroke | Systemic Embolism 821 1,964 0.62 (0.41 - 0.92)
209 184 0.36 (0.10 - 1.24)
Clinically Relevant Bleeding 181 149 0.26 (0.07 - 0.97)
491 1,135 0.90 (0.59 - 1.36) 31 28 0.20 (0.02 - 1.92)
Stroke 67 75 0.37 (0.03 - 4.61)
428 669 0.84 (0.47 - 1.49)
31 28 0.91 (0.12 - 6.72) Major Bleeding 181 0.29 (0.08 - 1.12)
149
491 943 0.65 (0.39 - 1.06)
Systemic Embolism 342 542 0.68 (0.39 - 1.18)
209 184 0.38 (0.15 - 0.92) Minor Bleeding 142 109 1.59 (0.52 - 4.82)
611 1,097 1.01 (0.75 - 1.36)
All-cause Mortality 170 144 0.68 (0.39 - 1.20)
31 28 0.67 (0.15 - 3.06)

Favors VKA Favors DOACs DOACs therapy was not associated with reduced efficacy and safety endpoints
0 1 5
896 1,755 1.11 (0.92 - 1.33)
Conclusion compared to VKAs therapy, except for fewer haemorrhagic events. Rivaroxaban
Thrombus Resolution therapy had a significant reduction in systemic embolic and hemorrhagic events.
209 184 1.51 (0.96 - 2.37)