An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution

TL;DR

This study compares direct oral anticoagulants and warfarin for resolving heart blood clots after heart attacks, finding them equally effective.

Contribution

An updated meta-analysis comparing DOACs and warfarin for LVT resolution using recent RCT data.

Findings

DOACs and warfarin showed similar LVT resolution rates at 3 months (86% vs. 81%).

No significant difference in bleeding or thromboembolic complications between the two groups.

Low heterogeneity suggests consistent results across the included trials.

Abstract

Background: Left ventricular thrombus (LVT) remains a well-recognized complication following myocardial infarction (MI). Whilst vitamin K antagonists (VKAs) have traditionally been the cornerstone of management, direct oral anticoagulants (DOACs) have been increasingly utilized despite limited data to support this. We sought to perform an up-to-date meta-analysis of all randomized controlled trials (RCTs) comparing DOACs to VKAs for LVT resolution. Methods: A systematic search of major scientific databases was performed to identify RCTs published until May 2025. The primary efficacy endpoint was complete LVT resolution at 3 months. The risk ratio (RR) and 95% confidence intervals (CIs) of the individual RCTs were pooled via the inverse-variance method and random-effects model. Results: Seven RCTs involving 554 patients with a mean age of 54 years were included in the meta-analysis. At 3 months, there was no difference in the rate of LVT resolution between those in the DOAC arm and the warfarin arm (86% vs. 81%, RR 1.01 [95%CI 0.93–1.10], p = 0.76). There was low heterogeneity at I2 = 15%. There was no difference in major or clinically significant bleeding or in the composite of stroke or thromboembolic complications, although the 95%CIs were wide. Conclusions: DOACs appear to be comparable to warfarin in achieving LVT resolution at 3 months. These findings support the consideration of DOACs as alternatives to VKAs in selected patients for LVT resolution. Further adequately powered trials and head-to-head comparisons between DOACs are required to confirm their safety.

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