Are direct oral anticoagulants preferable to warfarin for the treatment of left ventricular thrombi? A Bayesian meta-analysis of randomized controlled trials

There is no clear consensus on the optimal choice of anticoagulant in patients with left ventricular thrombi (LVT). Given the potentially fatal complications associated with this disease entity, we performed a systematic review and meta-analysis of recent randomized clinical trials (RCTs) to synthesize the latest evidence on this topic. We performed a comprehensive search of electronic databases to identify RCTs comparing warfarin to direct oral anticoagulants (DOACs) in patients with LVT. A random-effects Bayesian analysis using a binomial-normal hierarchical model was performed to compare the two treatment options with regards to the risk of mortality, stroke, LVT resolution, and major bleeding. In an analysis comprising 3 RCTs (N = 139), there were no statistically significant differences regarding mortality (OR: 0.68; 95% CrI: 0.10 to 4.43), stroke (OR: 0.14; 95% CrI: 0.01 to 1.27), or LVT resolution (OR: 1.17; 95% CrI: 0.37 to 3.45). Major bleeding was significantly lower in the DOAC group (OR: 0.16; 95% CrI: 0.02 to 0.82). In patients with LVT, the currently available evidence from RCTs supports the use of DOACs rather than warfarin due to lower major bleeding risks and no evidence of inferiority with respect to mortality, stroke or LVT resolution. •Direct oral anticoagulants (DOAC) result in fewer major bleeding events in patients with left ventricular thrombi (LVT).•There is no evidence of DOAC inferiority to warfarin in terms of mortality or stroke in patients with LVT.•There is no evidence of DOAC inferiority to warfarin in terms of LVT resolution.