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Anticoagulation for Left Ventricular Thrombosis Post-Myocardial Infarction – Current Recommendations and Future Perspectives

Mihai Ștefan Cristian Haba
Mihai Ștefan Cristian Haba
, 
Andreea-Simona Ungurenașu
Andreea-Simona Ungurenașu
, 
Elena Cosmina Ciobanu
Elena Cosmina Ciobanu
, 
Florin Mitu
Florin Mitu
, 
Radu Stefan Miftode
Radu Stefan Miftode
 e 
Ovidiu Mitu
Ovidiu Mitu
   | 04 giu 2022
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Article Category: Review
Pubblicato online: 04 giu 2022
Pagine: 22 - 27
DOI: https://doi.org/10.2478/rjc-2022-0005
Parole chiave
© 2022 Mihai Ștefan Cristian Haba et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

Virchow's triad adapted for left ventricular thrombosis (LVT) (modified after Delewi, et al.5).
Virchow's triad adapted for left ventricular thrombosis (LVT) (modified after Delewi, et al.5).

Figure 2

Transthoracic echocardiography of the left ventricle. Thrombus (arrows) attached to the apical septal wall in a patient with ischemic cardiomyopathy.
Transthoracic echocardiography of the left ventricle. Thrombus (arrows) attached to the apical septal wall in a patient with ischemic cardiomyopathy.

Figure 3

Algorithm for the diagnosis of LVT in reperfused STEMI patients. Abbreviations: LV – left ventricle, TTE – transthoracic echocardiography, CMR – cardiac magnetic resonance imaging (adapted after Bulluck, et al.12)
Algorithm for the diagnosis of LVT in reperfused STEMI patients. Abbreviations: LV – left ventricle, TTE – transthoracic echocardiography, CMR – cardiac magnetic resonance imaging (adapted after Bulluck, et al.12)

Guidelines for management of left ventricular thrombosis

LVT Recommendation
  STEMI Guidelines
ACC/AHA-201313
Patient with STEMI and DAPT+VKA with INR target 2–2.5

asymptomatic LVT

at high risk of developing LVT
ESC 2012
LVT VKA for a minimum of 3 months
ESC 201715
LVT Anticoagulation should be administered for up to 6 months guided by repeated imaging
  Stroke Guidelines
AHA/ASA 201416
Patient with ischemic stroke or TIA:

in setting of acute MI complicated by LVT

VKA therapy intolerance

in setting of acute MI at high risk of LVT

VKA for 3 months (INR target 2–3)

LMWH or DOAC (rivaroxaban, apixaban or dabigatran) for 3 months

Consider VKA therapy (INR target 2–3)
AHA/ASA 202117
Patient with stroke or TIA:

LVT

new LVT (< 3 months)

in setting of acute MI at high risk of LVT

warfarin for at least 3 months

the safety of anticoagulation with DOAC is uncertain

empirical anticoagulation for 3 months
  CHEST guidelines
ACCP 201218
Patient with anterior MI + LVT/high risk for LVT

with no stent

PCI with BMS

PCI with DES

VKA + low dose of aspirin for 3 months

triple therapy (VKA + aspirin + clopidogrel) for 1 month, then VKA + one antiplatelet for the next 2 months

triple therapy (VKA + aspirin + clopidogrel) for 3–6 months

 		Then discontinue warfarin and continue DAPT for up to 12 months as per ACS recommendation
Patient with LV systolic dysfunction + LVT without CAD VKA for 3 months with INR target 2–3
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Inglese
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Medicine, Clinical Medicine, Internal Medicine, Cardiology, Pediatrics and Juvenile Medicine, Paediatric Cardiology, Surgery, Cardiac Surgery
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