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Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation myocardial infarction

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Abstract

Background: Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking. Methods: We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events. Results: In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89–2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90–3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73–3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14–0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09–0.57), p = 0.001]. Conclusion: In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.

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Data availability

The datasets used and/or analyzed in this study are available from the corresponding author upon reasonable request.

Abbreviations

LVT:

Left ventricular thrombus

STEMI:

ST-Elevation myocardial infarction

PCI:

Percutaneous coronary intervention

VKA:

Vitamin K Antagonists

TTE:

Transthoracic echocardiography

WBC:

White blood cell count

MPV:

Mean platelet volume

LVEF:

Left ventricular ejection fraction

LVEDD:

Left ventricular end-diastolic dimension

LV aneurysm:

Left ventricular aneurysm

TIMI:

Thrombolysis in myocardial infarction

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Acknowledgements

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Funding

This work was supported by grants from Science and technology project of Jilin Provincial Department of Education (JJKH20190062KJ) and Science and Technology of Jilin Province (20180520054JH and 20200801076GH).

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Author notes

  1. Zhongfan Zhang and Daoyuan Si both are the 1st authors.

Authors and Affiliations

  1. Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China

    Zhongfan Zhang, Daoyuan Si, Qian Zhang, Miao Yu, Zhenya Jiang, Delin Li, Ping Yang & Wenqi Zhang

  2. Department of Gastroenterology, Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China

    Ming Qu

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  1. Zhongfan Zhang
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Contributions

ZZ, DS, and WZ conceived and designed the study. ZZ and QZ collected and analyzed data, performed the literature search. ZZ and MY drafted the manuscript. DS and WZ interpreted the data and made a critical revision to the manuscript. MQ, MY, ZJ, DL contributed to data collection and performed the literature search. WZ provided consultation, participated in the coordination of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Wenqi Zhang.

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This retrospective study was reviewed and approved by the ethical review board of China-Japan Union Hospital of Jilin University. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Zhang, Z., Si, D., Zhang, Q. et al. Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation myocardial infarction. Heart Vessels 37, 374–384 (2022). https://doi.org/10.1007/s00380-021-01921-z

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