Prophylactic anticoagulation for left ventricular thrombus in patients with anterior myocardial infarction

Abstract Introduction Left ventricular (LV) thrombus is a notable complication of anterior acute myocardial infarction (MI). The general consensus for treatment of this complication is anticoagulation AC) with a vitamin K antagonist (VKA) upon diagnosis. However, evidence regarding use of prophylactic AC to prevent LV thrombus in patients with anterior MI remains inconclusive. Purpose We performed a systematic review and meta-analysis to assess the clinical risks and benefits of prophylactic AC in patients with anterior MI. Methods A literature search was conducted looking for studies reporting on use of prophylactic AC in patients with anterior MI and evaluating clinical and safety endpoints. The clinical endpoints of interest included all-cause mortality, LV thrombus formation, and cerebrovascular accidents (CVA) or transient ischemic attacks (TIA). Safety endpoints included risk of any type of reported bleeding and risk of major bleeding. The search was performed using the databases PubMed, Web of Science, and Embase and was not restricted by time or publication status. Results A total of 8 studies with 979 patients with anterior MI (497 treated with prophylactic AC vs. 482 not treated with AC) were included. Mean follow-up was 15.8 months (ranging 0.5 - 96 months), mean age was 61.3, 72% were men, mean LVEF was 43% (ranging 22% - 60%). AC used included VKA, DOACs, and heparin products. In patients with anterior MI, use of AC was associated with significantly lower risk of all-cause mortality when LVEF is 40% but not in patients with LVEF 40% (OR 0.4, 95% CI 0.17-0.91; p=0.03; OR 1.11, 95% CI 0.66-1.85; p=0.70). Use of AC was associated with lower risk of LV thrombus formation regardless of LVEF (OR 0.29, 95% CI 0.15-0.58; p0.01). In patients with anterior MI, use of AC was associated with a non-statistically significant trend toward lower risk of CVA/TIA when LVEF is or = 40% (OR 0.44, 95% CI 0.14-1.33; p=0.15). Use of AC was associated with increased risk of any bleeding in patients with anterior MI and LVEF or = 40% but was not associated with increased risk of major bleeding in patients with anterior MI regardless of LVEF (OR 5.03, 95% CI 1.08-23.43; p=0.01; OR 1.17, 95% CI 0.87-1.58; p=0.30). Conclusion In patients who suffer from anterior MI, use of prophylactic therapeutic anticoagulation appears to be beneficial in preventing LV thrombus formation. Use of AC may also lower the risk of adverse cardiovascular outcomes such as all-cause mortality, however this effect appears to be dependent on LVEF, with benefit specifically seen in patients with LVEF or = 40%. Use of AC may increase the risk of any bleeding but does not appear to increase the risk of major bleeding. Further studies are needed to further establish the utility of therapeutic AC in patients with anterior MI, with particular focus on benefits based on LV systolic function.Figure 1 Figure 2