LV Thrombus After Acute MI

Authors:
McCarthy CP, Vaduganathan M, McCarthy KJ, et al.
Citation:
Left Ventricular Thrombus After Acute Myocardial Infarction: Screening, Prevention, and Treatment. JAMA Cardiol 2018;May 9:[Epub ahead of print].

The following are key points to remember from this review article about left ventricular (LV) thrombus after acute myocardial infarction (MI):

  1. LV thrombus is not an uncommon complication of acute MI, and is associated with systemic thromboembolism.
  2. Contemporary epidemiologic data suggest the incidence of LV thrombus, detected using optimal imaging modalities, may be as high as 15% in patients with ST-segment elevation MI (STEMI) and up to 25% in patients with anterior MI.
  3. Standard transthoracic echocardiography (TTE) is typically the screening modality of choice for LV thrombus detection and should be performed within 24 hours of admission in those at high risk for apical LV thrombus (e.g., those with large or anterior MI or those receiving delayed reperfusion). If (1) the LV apex is poorly visualized, (2) anterior or apical wall motion abnormalities are present, or (3) high apical wall motion scores are calculated (≥5 on noncontrast TTE), contrast TTE or cardiac magnetic resonance should be considered based on local availability and resources.
  4. The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) STEMI guidelines advise that oral anticoagulation (OAC) may be considered in patients with STEMI with anterior apical akinesis or dyskinesis to prevent LV thrombus formation. Similarly, the AHA/American Stroke Association 2014 guidelines on stroke prevention advise that anticoagulation may be considered for 3 months in patients with acute anterior STEMI and ischemic stroke or transient ischemic attack who have anterior apical akinesis or dyskinesis.
  5. In patients with a diagnosed LV thrombus, OAC should be started immediately. The 2013 ACCF/AHA STEMI guidelines advise that it is reasonable to add OAC to dual antiplatelet therapy among patients with STEMI and asymptomatic LV thrombus for 3 months, targeting a lower international normalized ratio (INR) goal of 2.0-2.5. The AHA/American Stroke Association 2014 stroke prevention guidelines recommend a similar duration, targeting a higher INR of 2.5.
  6. The European Society of Cardiology 2017 STEMI guidelines advised that once an LV thrombus is diagnosed, OAC should be considered for up to 6 months, guided by repeated echocardiography and with consideration of bleeding risk and need for concomitant antiplatelet therapy.
  7. The optimal duration of OAC in these patients is unclear, and decisions regarding continuation of OAC should be made on a case-by-case basis.
  8. In 2014, the AHA/American Stroke Association guidelines on stroke prevention introduced a new recommendation advising that low molecular weight heparin, dabigatran, rivaroxaban, or apixaban may be considered as an alternative to vitamin K antagonists for post-MI LV thrombus or anterior or apical wall motion abnormalities with an LV ejection fraction <40%, who are intolerant of vitamin K antagonists because of nonhemorrhagic adverse events.
  9. In addition to less potent antithrombotic regimens, adjunctive bleeding reduction or avoidance strategies should be considered. It is reasonable to treat all patients with proton-pump inhibitor therapy while receiving combination antithrombotic regimens.
  10. Given a lack of clear randomized clinical trial data and great variability in the presentation and associated complications of LV thrombus, individualized approaches are indicated. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to help delineate the optimal antithrombotic strategy for LV thrombus.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Anticoagulation Management and ACS, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Acute Coronary Syndrome, Anticoagulants, Brain Ischemia, Echocardiography, Heart Failure, Hemorrhage, Heparin, Low-Molecular-Weight, International Normalized Ratio, Ischemic Attack, Transient, Magnetic Resonance Imaging, Myocardial Infarction, Platelet Aggregation Inhibitors, Primary Prevention, Proton Pump Inhibitors, Stroke, Stroke Volume, Thromboembolism, Thrombosis, Vascular Diseases, Vitamin K


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