Background

Left ventricular (LV) thrombus commonly occurs following an acute myocardial infarction (AMI). The development of LV thrombus post-AMI is related to Virchow’s triad - Hypercoagulability, Stasis of blood and Endothelial dysfunction.

LV thrombus increases the risk of cardioembolic strokes. Warfarin is used in the acute phase to avoid thrombus propagation. However, there is no consensus on the period of anticoagulation. Data has yielded conflicting results and there is little on the early recurrence of ischaemic events due to clot disbursement after anticoagulation. Current evidence favours long-term anticoagulation in poor LV function. 
The objective is to determine the average time for LV thrombus resolution, the optimum time for anticoagulation and whether NOACs have a place in managing these patients.

Method

A literature review was conducted using cardiology and stroke articles.

Results

One study found that in patients with LV thrombus whose warfarin was in therapeutic range, the incidence of systemic embolism was <3%. In those with subtherapeutic levels, the incidence was 18%. On average, 8.5% suffered major bleeding events. However, on literature review, there was no information available on the recommended duration of anticoagulation in patients with LV thrombus, nor was there any evidence on the use of NOACs over warfarin.

Conclusion

There is no clear guidance on the duration or type of anticoagulation that should be used in LV thrombus. In conclusion, we propose a randomised-controlled trial (or extrapolation from a registry) to ascertain the optimum time period for anticoagulation. Data is also needed to establish the benefit of NOACs over warfarin.

ANTICOAGULATION FOR STROKE PREVENTION IN LEFT VENTRICULAR THROMBUS: UNCERTAINTIES