Robinson AA, Trankle CR, Eubanks G, Schumann C, Thompson P, Wallace RL, Gottiparthi S, Ruth B, Kramer CM, Salerno M, et al. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol. 2020;5:685-692.
In this entry, I discuss the RED-VELVT observational study by Austin A. Robinson and colleagues about treating left ventricular (LV) thrombi with direct oral anticoagulants (DOACs) compared to warfarin and looking at rates of embolic events between the two treatment modalities.
Anecdotal data from the nineties, as well as the early 2000s, demonstrated a lower risk of systemic embolization with the use of warfarin or low molecular weight heparin (LMWH) compared to antiplatelets for LV thrombi. However, with the arrival of DOACs, anticoagulation therapy has been revolutionized due to ease of administration, no requirement for daily INR checks, no need for dietary alterations, and lower risk of bleeding events, to name a few. The benefit of DOACs for treatment of left atrial (LA) thrombus was noted in the X-TRA trial, and further benefit of DOACs was also seen in patients requiring anticoagulation for cardioversion (ENSURE-AF, EMANATE). Noting the benefits of DOACs in treating LA thrombus, many physicians have extrapolated the use of DOACs to treat LV thrombus. However, there has been no study to date to evaluate if DOACs fare better, worse, or the same compared to warfarin to reduce embolic events in patients with LV thrombi, and the authors in this study have attempted to answer this question.