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DOACs vs Warfarin for Post-myocardial Infarction Left Ventricular Thrombus: A GRADE-assessed Meta-Analysis With Trial Sequential Analysis of Randomized Trials

Year: 2026
Type: review
Abstract: Background and PurposeCurrent 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.MethodsWe 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.ConclusionDOACs 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.
DOI: 10.1177/10760296261468457
Authors: Ahmed Elbataa, Ameer Awashra, Ahmed Elazab, Noha Hammad, Ahmed Mansour, Amro Ali, Mohamed Yasser Elnaggar, Elsayed Balbaa, Abdalhakim Shubietah, Mohamed S. Elgendy, Mohammed A. Elbahloul, Fawzi Zghyer, Mohammed Al-Sadawi, Amr Salama
Institutions: Al-Azhar University, An-Najah National University, South Valley University, Port Said University, Community Regional Medical Center, Mansoura University, Alexandria University, Advocate Illinois Masonic Medical Center, Tanta University, Kafrelsheikh University, Cleveland Clinic, University of Michigan, University of Alabama at Birmingham
Language: English
Field: Medicine
Open Access status: gold
Estimated APC paid: $2,650
OpenAlex ID: W7168128596
FWCI:
Cites: 31
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Related to: 10