What’s the optimal duration of anticoagulation in patients with left ventricular thrombus?

ABSTRACT

Introduction

Left ventricular thrombus (LVT) occurs in acute myocardial infarction and in ischemic and non-ischemic cardiomyopathies. LVT may result in embolic stroke. Currently, the duration of anticoagulation for LVT is unclear. This is an important clinical question as prolonged anticoagulation is associated with increased bleeding risks, while premature discontinuation may result in embolic complications.

Areas covered

There are no randomized trial data regarding anticoagulation duration for LVT. Guidelines and expert consensus recommend anticoagulation for 3–6 months with cessation of anticoagulation if interval imaging demonstrates thrombus resolution. Cardiac magnetic resonance imaging (CMR) is more sensitive and specific compared to echocardiography for LVT detection, and may be appropriate for high-risk patients. Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia.

Expert opinion

CMR will likely be increasingly used for LVT surveillance to guide anticoagulation duration. Further research is needed to determine which patients with persistent LVT on CMR benefit from prolonged anticoagulation.

KEYWORDS:

• Cardiac imaging
• cardiac magnetic resonance imaging
• cardiomyopathy
• echocardiography
• left ventricular thrombus
• thrombosis

Article highlights

• Prolonged anticoagulation is associated with increased bleeding, while premature discontinuation of anticoagulation may result in thrombus recurrence or embolism.

• There are presently no randomized trials to define a precise duration of anticoagulation for LVT.

• Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia.

• Interval cardiac magnetic resonance imaging may be helpful to assess for LVT resolution and hence guide cessation of anticoagulation.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

CH Sia was supported by the National University of Singapore Yong Loo Lin School of Medicine’s Junior Academic Fellowship Scheme.