Management of Patients at Risk for and With LV Thrombus: Key Points

Levine GN, McEvoy JW, Fang JC, et al., on behalf of the American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Stroke Council.
Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation 2022;Sep 15:[Epub ahead of print].

The following are key points to remember about this scientific statement from the American Heart Association (AHA) for the management of patients at risk for and with left ventricular (LV) thrombus:

  1. Decisions concerning the diagnosis, prevention, and treatment of LV thrombus remain challenging.
  2. Management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant (OAC) therapy to dual antiplatelet therapy (DAPT), the availability of direct oral anticoagulants (DOACs) as a potential alternative option to traditional vitamin K antagonists (VKAs), and the use of diagnostic modalities such as cardiac magnetic resonance imaging (CMR), which has greater sensitivity for LV thrombus detection than echocardiography.
  3. This AHA scientific statement was commissioned with the goals of addressing eight key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction (MI), prevention and treatment in dilated cardiomyopathy (DCM), management of mural (laminated) thrombus, imaging of LV thrombus, DOACs as an alternative to warfarin, treatments other than OACs for LV thrombus (e.g., DAPT, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy.
  4. This scientific statement suggests that CMR may be most appropriate when: a) there is the suggestion of a possible LV thrombus on echocardiogram but echocardiography imaging even with an ultrasound-enhancing agent is not diagnostic, and b) echocardiography does not demonstrate LV thrombus but a clinical concern remains (for example, cardioembolic stroke).
  5. Given the relatively weak data supporting prophylactic (preventive) OAC in patients with acute anteroapical ST-segment elevation myocardial infarction (STEMI) treated with reperfusion therapy (usually primary percutaneous coronary intervention [PCI]) and anteroapical akinesis, any such consideration of OAC should weigh and incorporate the perceived risk of thrombus formation and bleeding and involve shared decision making. If OAC is initiated, a treatment duration might be 1–3 months, depending on bleeding risk.
  6. On the basis of reasonable data and evidence, post-MI patients with LV thrombus should be treated with OAC, typically for a duration of 3 months.
  7. Based on reasonable randomized data, patients with DCM should not be prophylactically treated with OAC, with the possible exception of those with specific cardiomyopathies (for example, takotsubo syndrome, LV noncompaction, eosinophilic myocarditis, peripartum cardiomyopathy, and cardiac amyloidosis) with associated factors that increase the risk of LV thrombus formation, in which cases OAC could be considered.
  8. On the basis of limited data, patients with nonischemic cardiomyopathy with LV thrombus should be treated with OAC for at least 3–6 months, with discontinuation if LV ejection fraction improves to >35% (assuming resolution of the LV thrombus) or if major bleeding occurs. There are insufficient study data to determine whether OAC should be continued indefinitely.
  9. On the basis of limited data, it may be prudent to treat patients with OAC for newly diagnosed mural (laminated) LV thrombus as one would a patient with a protruding or mobile thrombus.
  10. On the basis of supportive though insufficiently powered randomized data, in patients with LV thrombus, DOAC seems to be a reasonable alternative to warfarin.
  11. On the basis of consensus opinion, in some patients with persistent LV thrombus, particularly a protruding or mobile thrombus, a trial of an alternative OAC or low molecular weight heparin (LMWH) (for example, VKA if on DOAC, DOAC if on VKA with repeatedly subtherapeutic international normalized ratio [INR], LMWH if on VKA with therapeutic INRs) is not unreasonable. On the other hand, also on the basis of consensus opinion, discontinuation of OAC in patients with persistent mural (laminar) thrombus, particularly if the thrombus becomes organized or calcified, is not unreasonable.
  12. Future research should investigate:
    • The natural history of mural (laminated) LV thrombus and whether the duration of anticoagulation should be tailored to the morphology of the LV thrombus;
    • The benefits of OAC in addition to antiplatelet therapy in patients with STEMI who have undergone primary PCI;
    • Whether indefinite anticoagulation is indicated in patients with DCM or with prior (not acute or recent) MI who develop LV thrombus; and
    • The optimal anticoagulants (e.g., VKA, DOAC, LMWH) in specific clinical settings.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Anticoagulants, Cardiomyopathies, Cardiomyopathy, Dilated, Diagnostic Imaging, Echocardiography, Heart Failure, Hemorrhage, Heparin, Low-Molecular-Weight, Magnetic Resonance Imaging, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Reperfusion, Secondary Prevention, ST Elevation Myocardial Infarction, Thrombosis, Vascular Diseases, Vitamin K, Warfarin

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