DOACs vs warfarin for post-myocardial infarction left ventricular thrombus: A GRADE-assessed meta-analysis with trial sequential analysis of randomized trials

Authors

• Ahmed Elbataa, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Ameer Awashra, Department of Medicine, An Najah National University, Nablus, Palestine.
• Ahmed Elazab, Faculty of Medicine, South Valley University, Qena, Egypt.
• Noha Hammad, Faculty of Medicine, Port-Said University, Port-Said, Egypt.
• Ahmed Mansour, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
• Amro Ali, Department of Medicine, Community Regional Medical Center, Fresno, CA, USA.
• Mohamed Yasser Elnaggar, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
• Elsayed Balbaa, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
• Abdalhakim Shubietah, Advocate Health - MidwestFollow
• Mohamed S. Elgendy, Faculty of Medicine, Tanta University, Tanta, Egypt.
• Mohammed A. Elbahloul, Faculty of Medicine, Kafr El Sheik University, Kafr El Sheikh, Egypt.
• Fawzi Zghyer, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
• Mohammed Al-Sadawi, Department of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.
• Amr Salama, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

Recommended Citation

Elbataa A, Awashra A, Elazab A, et al. DOACs vs Warfarin for Post-myocardial Infarction Left Ventricular Thrombus: A GRADE-assessed Meta-Analysis With Trial Sequential Analysis of Randomized Trials. Clin Appl Thromb Hemost. 2026;32:10760296261468457. doi:10.1177/10760296261468457

Abstract

Background and Purpose: Current AHA and ACC guidelines warrant studies comparing direct oral anticoagulant (DOAC) and warfarin for post-myocardial infarction (MI) left ventricular thrombus (LVT). DOAC is increasingly considered due to its minimal monitoring requirement. However, DOAC efficacy in LVT resolution remains uncertain. We aim to evaluate the efficacy and safety of DOAC versus warfarin in post-MI LVT. Methods: We searched Medline/PubMed, Scopus, Web of Science, and Cochrane. Library databases from inception up to August 2025. The primary outcome was LVT resolution. Secondary outcomes included all-cause death, stroke, and major bleeding rates.ResultsFour RCTs encompassing 396 patients (240 DOAC, 156 warfarin) were included. LVT resolution occurred in 90.0% of DOAC patients versus 86.5% in warfarin patients, with no significant difference (RR 0.99, 95% CI 0.94-1.06, p=0.84). Subgroup analysis revealed comparable outcomes for both rivaroxaban and apixaban versus warfarin. Stroke rates were higher in DOAC compared to warfarin but not statically significant between groups (2.5% vs 1.2%, RR 1.37, 95% CI 0.15-12.95). Similarly, all-cause mortality (3.3% vs 1.9%) and major bleeding (1.6% vs 1.9%) showed no significant differences.Conclusion: DOACs demonstrate comparable efficacy and safety to warfarin for post-MI LVT management, with similar rates of thrombus resolution and complications. However, TSA indicates that current evidence is underpowered, and further large-scale randomized trials are required to confirm these findings.

Type

Article

PubMed ID

42439487