Efficacy and safety of direct oral anticoagulants versus vitamin K antagonist in patients with left ventricular thrombus: A meta-analysis of randomized controlled trials.

Background: While vitamin K antagonist (VKA) has traditionally been the preferred treatment for left ventricle (LV) thrombus, the comparative efficacy and safety of direct oral anticoagulants (DOACs) with VKA in this setting remain unelucidated.

Methods: A comprehensive literature search of PubMed and Google Scholar was conducted through May 7, 2025, to identify randomized controlled trials (RCTs) comparing DOACs with VKA in patients with LV thrombus. The primary endpoint was complete resolution of LV thrombus. Secondary endpoints included stroke, systemic embolism, the composite of both stroke and systemic embolism, major bleeding, and all-cause mortality. Both pairwise and network meta-analyses were performed using a random-effects model to synthesize the effect estimates.

Results: Eight RCTs comprising a total of 576 patients were included. Collectively, 88.9 % of the patients treated with DOACs and 81.7 % of those receiving VKA experienced LV thrombus resolution, with a synthesized risk ratio (RR) of 1.01 [95 % confidence interval (CI), 0.94 to 1.07]. No significant differences were observed between the two groups for stroke (RR, 0.75; 95 % CI, 0.25 to 2.19), systemic embolism (RR, 0.21; 95 % CI, 0.01 to 4.58), the composite of stroke and systemic embolism (RR, 0.64; 95 % CI, 0.17 to 2.32), major bleeding (RR, 0.43; 95 % CI, 0.16 to 1.19), or all-cause mortality (RR, 0.92; 95 % CI, 0.36 to 2.31). A network meta-analysis showed no statistically significant differences across the anticoagulants in any clinical endpoint.

Conclusion: DOACs showed comparable efficacy and safety to VKA in managing LV thrombus, supporting their potential role as a viable alternative anticoagulation strategy.