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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 26-29

Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series


Department of Cardiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India

Date of Submission24-Jan-2022
Date of Acceptance15-Feb-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Dr. Archit Dahiya
74-R Model Town, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_5_22

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  Abstract 


Introduction: Left ventricular (LV) thrombus is a known complication of myocardial infarction (MI) and it usually occurs in areas of poorly contracting LV muscle as a result of endocardial injury with associated inflammation. There is a high risk of embolization within 3 months among patients with MI complicated by mural thrombus and this risk is maximum during the first 1–2 weeks. We report a case series of five patients who presented with acute coronary syndrome with LV apical thrombus and treated with triple anti-thrombotic therapy of rivaroxaban, aspirin, and clopidogrel.
Case Series: Our series involves 5 cases who developed LV apical thrombus after acute coronary syndrome. Four patients had anterior wall ST-elevation MI (STEMI) whereas 1 patient had inferior wall STEMI. One of the patients with anterior STEMI also had COVID pneumonitis. All of these patients received triple anti-thrombotic therapy consisting of tab Aspirin 75 mg OD, tab clopidogrel 75 mg OD, and tab rivaroxaban 20 mg OD for 3 months duration. Repeat ECHO after 3 months showed complete resolution of LV thrombus in all of our cases.
Discussion: LV thrombus reported in STEMI patients is from 1.6% up to 39% in various studies. The incidence of LV thrombus is on decreasing trend as a result of modern revascularization strategies. The role of novel oral anticoagulants (NOACs) in treating LV thrombus is scant as compared to oral Vitamin K antagonists (VKAs) like warfarin. The current recommendation for anticoagulation in the presence of a LV thrombus after acute coronary syndrome is with VKAs for up to 6 months.
Conclusion: Although there is uncertainty in decision-making regarding antithrombotic therapy, our case series demonstrate that triple antithrombotic therapy with NOACs results in resolution of LV thrombus without any additional bleeding events in patients presenting with acute coronary syndrome. NOACs have an advantage of not requiring PT/INR monitoring and have less bleeding complications. Further large-scale research or randomized controlled trials are needed to find the optimal therapies in such cases.

Keywords: Acute coronary syndrome, left ventricular thrombus, novel oral anticoagulant


How to cite this article:
Dahiya A, Joshi P, Sinha RP, Wardhan H. Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series. Heart India 2022;10:26-9

How to cite this URL:
Dahiya A, Joshi P, Sinha RP, Wardhan H. Novel oral anticoagulant in treatment of left ventricular thrombus in acute coronary syndrome – A case series. Heart India [serial online] 2022 [cited 2022 May 16];10:26-9. Available from: https://www.heartindia.net/text.asp?2022/10/1/26/343069




  Introduction Top


Left ventricular (LV) thrombus is a known complication of myocardial infarction (MI) and it usually occurs in areas of poorly contracting LV muscle as a result of endocardial injury with associated inflammation. There is a high risk of embolization within 3 months among patients with MI complicated by mural thrombus and this risk is maximum during the first 1–2 weeks. Risk factors for LV thrombus include extensive anterior wall ischemia, regional wall motion abnormality, aneurysm, reduced LV function, and larger infarct size.

Early detection and proper management of LV thrombus are essential as it has major impact on outcome of patient. Furthermore, COVID-19 infection can result in a hypercoagulable state which may consequently lead to sooner than anticipated development of LV thrombus.[1] We report a case series of five patients who presented with acute coronary syndrome with LV apical thrombus and treated with triple anti-thrombotic therapy (TAT) of rivaroxaban, aspirin, and clopidogrel.


  case series Top


Our series involves 5 cases [Table 1] who developed LV apical thrombus after acute coronary syndrome. 4 patients had anterior wall ST-elevation MI (STEMI) whereas 1 patient had inferior wall STEMI. One of the patients with anterior STEMI also had COVID pneumonitis. His high resolution computed tomography (CT) thorax showed areas of ground glass haziness with reticulations with CT severity score of 7/25.
Table 1: Characteristics of patients

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All of these patients received TAT consisting of tab Aspirin 75 mg OD, tab Clopidogrel 75 mg OD, and tab Rivaroxaban 20 mg OD for 3 months duration. Repeat ECHO after 3 months showed complete resolution of LV thrombus in all of our cases [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. No major bleeding event was observed during the course of this therapy.
Figure 1: Case 1. (a) Two-dimensional Echo: Apical 4-chamber view showing LV apical thrombus measuring 1.20 cm × 2.21 cm, (b) Two-dimensional Echo on follow up: Apical 4-chamber view showing no evidence of LV apical thrombus

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Figure 2: Case 2. (a) Two-dimensional Echo: Apical 4-chamber view showing LV apical thrombus measuring 1.51 cm × 1.88 cm, (b) Two-dimensional Echo on follow up: Apical 4-chamber view showing no evidence of LV apical thrombus

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Figure 3: Case 3. (a) Two-dimensional Echo: Apical 5-chamber view showing LV apical thrombus measuring 1.7 cm × 2.33 cm, (b) Two-dimensional Echo on follow up: Apical 4-chamber view showing no evidence of LV apical thrombus

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Figure 4: Case 4. (a) Two-dimensional Echo: Apical 4-chamber view showing LV apical thrombus measuring 1.43 cm × 2.43 cm, (b) Two-dimensional Echo on follow up: Apical 4-chamber view showing no evidence of LV apical thrombus

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Figure 5: Case 5. (a) Two-dimensional Echo: Apical 4-chamber view showing LV apical thrombus measuring 1.4 cm × 1.4 cm, (b) Two-dimensional Echo on follow up: Apical 4-chamber view showing no evidence of LV apical thrombus

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  Discussion Top


LV thrombus reported in STEMI patients is from 1.6% up to 39% in various studies.[2],[3],[4] It mostly occurs in large anterior wall MI patients and those presenting late (later than 12 h of onset of chest pain) with STEMI. It is also seen in patients with dilated cardiomyopathy or chagas disease.[5],[6] Patients with LV thrombus have increased risk for cardioembolic events

Combination of blood stasis, endothelial injury, and hypercoagulability (Virchow's triad) is a prerequisite for in vivo thrombus formation. All patients in our case series had acute MI and our case four also had COVID pneumonitis. Hypercoagulable state develops in patients with COVID-19 which may have subsequently led to acute coronary syndrome with LV dysfunction and this dysfunction in conjunction with COVID 19 may have further led to LV thrombus. In COVID-19, the development of LV thrombus has been reported previously also.[7],[8]

The incidence of LV thrombus is on decreasing trend as a result of modern revascularization strategies. The role of novel oral anticoagulants (NOACs) in treating LV thrombus is scant as compared to oral Vitamin K antagonists (VKAs) like warfarin. The current recommendation for anticoagulation in the presence of a LV thrombus after acute coronary syndrome is with VKAs for up to 6 months.[9]

In case of VKAs, thrombus resolution was dependent on time spent within the therapeutic range.[10] In view of the narrow therapeutic window of VKAs and difficulty for visiting hospital for frequent investigations (PT/INR monitoring) due to fear of COVID-19 pandemic, it was decided to start treatment of these patients with NOACs. All these patients on subsequent follow-up after 3 months showed complete resolution of LV thrombus.

Although Robinson et al.[11] reported higher risk of ischemic stroke and systemic emboli on anticoagulation with NOACs as compared with warfarin in patients with LV thrombus, we did not see any such complications in our case series.

Hofer et al. in 2020 reported incidence rate of LV thrombus after acute coronary syndrome of 2.5%. This study involved 43 patients with LV thrombus after ACS in which 23.3% received NOACs and 76.7% received VKAs for median duration of 24 weeks. No significant difference was seen between both groups. TAT was given in 69.8% of the patients with LV thrombus. They concluded that intensified anti-thrombotic treatment approach might be taken into account in patients with persistent LV thrombus and low bleeding risk.[12]

In a 2020 study by Lattuca et al. in on 159 cases of LV thrombus, NOACs were given in 22.6% patients, VKAs in 48.4% patients, low–molecular-weight heparin) in 23.3% and unfractionated heparin in 4.4% patients. Triple antithrombotic therapy was given in 35.2% patients. One-third of patients in this study did not achieve total LV thrombus regression highlighting that the current antithrombotic regimen needs improvement.[13]

Jones et al. in 2020 showed improved thrombus resolution in patients of postacute coronary syndrome having LV thrombus treated with NOACs compared to VKAs. Out of 101 patients with LV thrombus, 60 (59.4%) were treated with warfarin and 41 (40.6%) with NOAC therapy (rivaroxaban, 58.5%; apixaban, 36.5%; and edoxaban, 5%). NOACs group had a greater and earlier LV thrombus resolution (82% in NOACs vs. 64.4% in VKAs group at 1 year with P < 0.05). The incidence of major bleeding events was lower in the NOACs vs. VKAs group with no difference in rates of systemic thromboembolism.[14]


  Conclusion Top


Although there is uncertainty in decision-making regarding antithrombotic therapy, our case series demonstrates that triple antithrombotic therapy with NOACs results in resolution of LV thrombus without any additional bleeding events in patients presenting with acute coronary syndrome. NOACs have an advantage of not requiring PT/INR monitoring and have less bleeding complications. Further large-scale research or randomized controlled trials are needed to find the optimal therapies in such cases.

Ethical approval

This study was approved by Institutional Ethics Committee.

Authors' contributions

All authors contributed to the study conception, design, material preparation, data collection, and analysis. All authors have read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020;18:1023-6.  Back to cited text no. 1
    
2.
Kontny F, Dale J, Hegrenaes L, Lem P, Søberg T, Morstøl T. Left ventricular thrombosis and arterial embolism after thrombolysis in acute anterior myocardial infarction: Predictors and effects of adjunctive antithrombotic therapy. Eur Heart J 1993;14:1489-92.  Back to cited text no. 2
    
3.
McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL Jr., Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: Screening, prevention, and treatment. JAMA Cardiol 2018;3:642-9.  Back to cited text no. 3
    
4.
Robinson AA, Jain A, Gentry M, McNamara RL. Left ventricular thrombi after STEMI in the primary PCI era: A systematic review and meta-analysis. Int J Cardiol 2016;221:554-9.  Back to cited text no. 4
    
5.
Mir JU, Raheel Jahangir J, Asfandyar Q, Sher Ali K, Syed Abbas A, Muhammad Zeeshan H. Left ventricular thrombus in patients with acute anterior wall myocardial infarction. J Ayub Med Coll Abbottabad 2014;26:491-5.  Back to cited text no. 5
    
6.
Nunes MC, Kreuser LJ, Ribeiro AL, Sousa GR, Costa HS, Botoni FA, et al. Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease. Glob Heart 2015;10:151-7.  Back to cited text no. 6
    
7.
Farouji I, Chan KH, Abanoub R, Guron G, Slim J, Suleiman A. A rare case of co-occurrence of pulmonary embolism and left ventricular thrombus in a patient with COVID-19. SAGE Open Med Case Rep 2020;8:2050313X20974534.  Back to cited text no. 7
    
8.
Jadhav KP, Jariwala P. Intracardiac thrombus in COVID19 pandemic – Case series and review. Eur J Cardiovasc Med 2020;6. [doi: 10.5083/ejcm20424884.180].  Back to cited text no. 8
    
9.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.  Back to cited text no. 9
    
10.
Maniwa N, Fujino M, Nakai M, Nishimura K, Miyamoto Y, Kataoka Y, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J 2018;39:201-8.  Back to cited text no. 10
    
11.
Robinson AA, Trankle CR, Eubanks G, Schumann C, Thompson P, Wallace RL, et al. Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi. JAMA Cardiol 2020;5:685-92.  Back to cited text no. 11
    
12.
Hofer F, Kazem N, Schweitzer R, Horvat P, Winter MP, Koller L, et al. The prognostic impact of left ventricular thrombus resolution after acute coronary syndrome and risk modulation via antithrombotic treatment strategies. Clin Cardiol 2021;44:1692-9.  Back to cited text no. 12
    
13.
Lattuca B, Bouziri N, Kerneis M, Portal JJ, Zhou J, Hauguel-Moreau M, et al. Antithrombotic therapy for patients with left ventricular mural thrombus. J Am Coll Cardiol 2020;75:1676-85.  Back to cited text no. 13
    
14.
Jones DA, Wright P, Alizadeh MA, Fhadil S, Rathod KS, Guttmann O, et al. The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. Eur Heart J Cardiovasc Pharmacother 2021;7:398-404.  Back to cited text no. 14
    


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