Direct oral anticoagulants versus vitamin K antagonists for patients with left ventricular thrombus: a systematic review and meta-analysis.

INTRODUCTION:Although vitamin K antagonists (VKAs) are recommended as first-line anticoagulants for patients with left ventricular thrombus (LVT), accumulating evidence suggests direct oral anticoagulants (DOACs) could be safe alternatives for VKAs. Efficacy and safety of DOACs should be assessed to justify their usage for LVT patients. OBJECTIVES:To compare the efficacy and safety of DOACs and VKAs for the treatment of LVT. PATIENTS AND METHODS:We performed a meta-analysis of observational studies to compare DOACs to VKAs in LVT patients. The PubMed and EMBASE databases were searched for articles published until November 12, 2020. Pooled effects were estimated using Mantel-Haenszel method and presented as risk ratios (RR) using fixed-effect model. Reporting followed the Meta-analyses of observational studies in epidemiology (MOOSE) guideline. RESULTS:A total of 2467 LVT patients from 13 studies were included. Compared with VKAs, DOACs showed similar efficacy in prevention of stroke or systemic embolism (RR: 0.96, 95% confidence interval [CI]: 0.80-1.16, P = 0.68) and thrombus resolution (RR: 0.88, 95% CI: 0.72-1.09, P = 0.26), but significantly lower risk of stroke (RR: 0.68, 95% CI: 0.47-1.00, P = 0.048). For safety outcomes, DOAC users showed similar risk of any bleedings (RR: 0.94, 95% CI: 0.67-1.31, P = 0.70), but lower risk of clinically relevant bleedings (RR: 0.35, 95% CI: 0.13-0.92, P = 0.03) compared with VKA users. CONCLUSIONS:Compared with VKAs, DOACs acquired similar efficacy and safety profile for patients with LVT, but could reduce the risk of strokes and clinically relevant bleedings.