Thread by @a_h_ghoneem

LV thrombi (LVT)

👉Are associated with systolic dysfunction.
👉Can occur in both ischemic & non-ischemic cardiomyopathy.
👉Carry a significant risk of systemic thromboembolism.

Management is mainly anticoagulation, but would you choose WARFARIN or a DOAC?? A #tweetorial 🧵

In this tweetorial, we will explore:

👉 The guideline recommendations for management of LV thrombus.

👉 The most recent evidence favoring warfarin.

👉 The most recent evidence favoring DOACs.

I feel comfortable with choosing between warfarin vs DOAC for patients with LV thrombi.

The 2013 ACC/AHA & the 2017 ESC STEMI guidelines recommend: WARFARIN for 3-6 months in pts with STEMI and LVT (Class IIa, LOE C).

Unfortunately, no large RCT’s to date have compared warfarin vs DOACs in LVT.

But several recent retrospective studies have addressed this ❓👇👇

In the RED VELVET study (Robinson et al, 2020)

👉514 patients with LVT in 3 centers

👉236 on warfarin, 121 on DOACs & 64 in the “treatment switching” group

👉DOACs were associated with a ⬆️ risk of stroke & systemic embolization

i.e Warfarin more effective ?🤔

Interestingly, there was no difference between warfarin and DOAC’s in the sub-group of patients with ischemic cardiomyopathy.

Definitely warrants future studies…

A contrasting study by Ali et al (2020)

👉 110 patients, single center

👉 60 on warfarin, 32 on DOACs

👉 DOACs were associated with a ⬇️ risk of stroke & systemic embolization, & with more thrombi resolving within the 1st month.

i.e DOACs more effective?🤔

And in between those opposing studies, 4 smaller studies found no difference between warfarin and DOACs in rates of LVT resolution, stroke/systemic embolization, or bleeding.

pubmed.ncbi.nlm.nih.gov/32598904/

pubmed.ncbi.nlm.nih.gov/32598904/

pubmed.ncbi.nlm.nih.gov/32144651/

pubmed.ncbi.nlm.nih.gov/33078629/

Confusing evidence?

Observational studies are usually "hypothesis-generating"

🔴prone to bias & confounding

🔴possible loss of follow-up

🔴Can't be used to demonstrate causality

⛔️Caution should be exercised before implementation of their results into clinical practice.

This is why we need RCT’s!

Although only 79 patients, this important 2021 trial by @yehiasaleh_MD et al is the first prospective, randomized clinical trial demonstrating that rivaroxaban was noninferior to warfarin.

However, this trial had its limitations:

🔴 Likely underpowered to detect a difference in embolic events
🔴 Unblinded
🔴 Non-inferiority study
🔴 LVT were assessed by TTE only (⬇️ sensitivity)

Again, interpret results with caution⛔️

After going over the recent evidence, I’ll end with a case to consider

60F, Ant STEMI & PCI to LAD 2 years ago.

Rx: Aspirin, Atorvastatin, Metoprolol, Sac-Val & Spironolactone

BMI 20. Cr & LFTs are WNL

TTE today shows a LVT

What would you recommend?

What would you recommend if the patient tell you that regular INR checks will be challenging due to work?

I feel comfortable with choosing between warfarin vs DOAC for patients with LV thrombi

I learned something in this Tweetorial that may change my clinical practice.

Let’s review!
👉LV thrombi are a RF for strokes & systemic embolization
👉Guidelines (2013/2017): warfarin for 3-6 months (Class IIa, LOE C)
👉Observational data is somewhat conflicting, however DOACs may be reasonable in certain patients
👉Prospective studies & RCT's are needed

Thank you for reading! Would love to hear any thoughts and feedback! #CardioTwitter

As always, thank you to the @cardionerds family for support and feedback @AmitGoyalMD @CBlumenthal2 @Dr_DanMD @karanpdesai @ThomasMDas

@tony_breu @AvrahamCooperMD @AdamRodmanMD @ShreyaTrivediMD @DrMarthaGulati @KTamirisaMD @HafizaKMD @DLBHATTMD @AnkurKalraMD @KBerlacher @mbelshazly @noshreza @JamalRanaMD @SaurabhSDani @mickeylev1 @SuzanneJBaron @SarjuGanatraMD