Management of Stroke Risk in Patients with Left Ventricular Thrombus

Educational Objectives

The goal of this program is to improve the management of left ventricular thrombus (LVT). After hearing and assimilating this program, the clinician will be better able to:

1. Outline the pathophysiology, epidemiology, and risk factors of LVT.
2. Implement guideline recommendations for the diagnosis, prevention, and management of LVT.

Summary

Left ventricular thrombus (LVT): pathophysiology — relates to stasis, hypercoagulability, and endothelial damage (Virchow triad); acute myocardial infarction (AMI) damages endothelium; stasis is attributed to LV wall motion abnormalities; colchicine is beneficial in post-MI patients; polypharmacy may be a concern for patients; epidemiology — incidence is decreasing (overall incidence is ≈3%); incidence of LVT post-anterior ST-segment elevation MI (STEMI) is ≈10%; ≈66% of patients developing LVT have chronically reduced ejection fraction while the rest have AMI; risk factors — the larger the thrombus, the higher the risk for stroke and systemic embolism (SSE); warfarin — for time in therapeutic range (TTR) <50%, the risk for embolization is ≈20% (for TTR >50%, ≈3%)

Warfarin (Coumadin, Jantoven): narrow TR; numerous drug and food interactions; in a large atrial fibrillation (AF) registry trial (ORBIT-AF), ≈66% of patients were in TR; in real-world setting, ≈50% of patients are in TR; direct oral anticoagulants (DOACs) are increasingly preferred

Imaging: cardiac MRI (CMR) is far superior to echocardiography (ECHO) in detecting LVT (≈100%); compared with ECHO, contrast ECHO (CE) has better sensitivity (≈67%); small thrombi detected on CMR carry a significant risk for embolism; ultrasound-enhancing agents (UAEs) include perflutren protein-type A microsphere injection (eg, Optison; has albumin) and perflutren lipid microsphere (eg, Definity; contraindicated in perflutren and polyethylene glycol allergy); UAEs are lipid-enhanced microbubbles and are exhaled by the patient; CE is recommended ≤24 hr of MI and, if negative, may be repeated at 72 hr or 2 wk; however, CE may be impractical and may be reserved for high-risk patients; although post-MI thrombus historically has been treated with triple therapy, recent data indicate that aspirin is not preferable, and a DOAC plus clopidogrel (eg, Deplatt, Iscover, Plavix) alone can be used following percutaneous coronary intervention; in high-risk patients, CMR (limited availability) or computed tomography (CT) can be used

Warfarin vs DOACs: Robinson et al (2020) — found that DOAC therapy was associated with a higher risk for SSE compared with warfarin; however, the methodology was suspect, and patients with chronic thrombi were more likely to receive warfarin (risk for stroke is lower for calcified thrombi); Coylewright et al (2023) — in a registry analysis, DOACs and warfarin were similarly effective in the management of LVT; No-LVT trial — in a small randomized trial, Abdelnabi et al (2021) randomized patients to warfarin vs rivaroxaban (RIV; Xarelto) 20 mg (with no run-in); traditionally, DOAC dosing is different for deep vein thrombosis or pulmonary embolism (age, body weight, and creatinine are not considered) vs AF; patients with low creatinine clearance were excluded; after 1 mo, RIV was more effective in resolution of LVT than warfarin; risk for SSE was lower with RIV, with a trend to less bleeding

American Heart Association Consensus Statement

Imaging: contrast-enhanced transthoracic ECHO may double the sensitivity and is the recommended technique for detection of LVT; transesophageal ECHO is not routinely useful, as apical thrombi are often missed; data on CT are limited; CMR is the gold standard, but patients may feel claustrophobic (takes 1-1.5 hr; preferred when contrast study is equivocal)

Prophylactic therapy after AMI: although LVT is a complication of anterior STEMI, data do not support OAC or antiplatelet therapy (APT), as prompt revascularization has reduced the risk for LVT; although a study that evaluated RIV 2.5 mg twice daily for 1 mo showed decreased risk for LVT, further research is needed

Treatment of LVT after AMI: patients with post-MI thrombi have a 5.5-fold increased risk for embolic events; the annual risk for stroke is 10% to 15% with a high (7-9) CHA₂DS2-VASc score (congestive heart failure, hypertension, age ≥75 yr [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease, age 65-74 yr, sex category [female]); anticoagulation (ACN), in addition to APT, confers benefits; after AMI and for ischemic cardiomyopathy outside of AMI, ACN is advisable for 3 to 6 mo

Prevention of LVT after dilated cardiomyopathy (DCM): a recent Cochrane review does not support use of OAC in patients with sinus rhythm and DCM; empiric OAC may be considered with shared decision-making in, eg, amyloidosis, Loeffler syndrome, eosinophilic cardiomyopathy, and LV noncompaction

Treatment of LVT in DCM: LVT occasionally occurs in idiopathic DCM; OAC is advisable for 3 to 6 mo; the risk for recurrence decreases with improved LV function

Mural thrombus: embolic risk may be low compared with a protuberant thrombus

DOAC vs warfarin: updated guidelines recommend treating LVT with DOAC or warfarin; a meta-analysis of 12 studies found no difference between DOACs and warfarin; in end-stage renal disease, warfarin may be considered, as data for using DOACs are lacking

Surgical excision of LVT: rarely performed; used in, eg, obstruction of LV flow, inability to tolerate ACN

Persistent LVT: occurs in 15% to 30% of cases; consider switching OAC for protuberant thrombus (if not calcified or laminar [less embolic risk]); consider shared decision-making for mural organized thrombus, which may become laminated or calcified after 3 to 6 mo of therapy; an aspiration thrombectomy device (eg, AngioVac) may be used to remove persistent left atrial thrombi and LVT

Readings

reed A, et al. Comparative study of oral anticoagulation in left ventricular thrombi (No-LVT Trial). J Am Coll Cardiol. 2021;77(12):1590-1592. doi:10.1016/j.jacc.2021.01.049; Coylewright M, Holmes DR, Kapadia SR, et al. DAPT is comparable to OAC following LAAC with WATCHMAN FLX: A national registry analysis. JACC Cardiovasc Interv. 2023;16(22):2708-2718. doi:10.1016/j.jcin.2023.08.013; Habash F, Vallurupalli S. Challenges in management of left ventricular thrombus. Ther Adv Cardiovasc Dis. 2017;11(8):203-213. doi:10.1177/1753944717711139; Levine GN, McEvoy JW, Fang JC, et al. Management of patients at risk for and with left ventricular thrombus: A scientific statement from the American Heart Association. Circulation. 2022;146(15):e205-e223. doi:10.1161/CIR.0000000000001092; Maniwa N, Fujino M, Nakai M, et al. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J. 2018;39(3):201-208. doi:10.1093/eurheartj/ehx551; Robinson AA, Trankle CR, Eubanks G, et al. Off-label use of direct oral anticoagulants compared with warfarin for left ventricular thrombi. JAMA Cardiol. 2020;5(6):685–692. Doi:10.1001/jamacardio.2020.0652.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Palli's lecture includes information related to the off-label or investigational use of a product, therapy, or device.

Acknowledgements

Dr. Palli was recorded at the 6th Annual New Jersey Neurovascular & Neurosciences Symposium, held on November 9, 2023, in Mount Laurel, NJ, and presented by Thomas Jefferson University. For more information about upcoming CME activities from this presenter, please visit Jefferson.cloud-cme.com. Audio Digest thanks the speakers and Thomas Jefferson University for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

NE150301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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