Management of Patients at Risk for and With Left Ventricular Thrombus

Publication Date: September 15, 2022
Last Updated: October 5, 2022

Tables

Table 1. Eight Key Clinical Management Issues Related to the Management of Patients at Risk for and With LV Thrombus

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  • Is echocardiography adequate for detection of suspected LV thrombus, or is CMR (or cardiac CT) indicated when there is concern for LV thrombus?
  • In the era of DAPT after ACS and PCI, which patients should be consid-ered for OAC therapy after anterior/apical MI and akinesis, particularly given the increased bleeding rates with combined OAC therapy and antiplatelet therapy?
  • In those patients with acute MI with visualized LV thrombus, when (if ever) can anticoagulation be stopped? Is a single echocardiogram after 3–6 mo of therapy not demonstrating LV thrombus enough to confidently discontinue?
  • Which, if any, patients with DCM or HFrEF (not related to acute MI) should be treated with preventive (prophylactic) OAC?
  • In those with DCM or HFrEF who form LV thrombus and thus may have a predilection to do this, can OAC ever be stopped (even if a follow-up echocardiogram demonstrates LV thrombus resolution)?
  • Is anticoagulation really indicated for laminated thrombus (not a more mobile, round, mural thrombus)?
  • Is DOAC a reasonable alternative to warfarin for the prevention and treat-ment of LV thrombus?
  • What management options are there in patients with persistent LV throm-bus despite therapy?

Table 2. Specific DCMs (Nonischemic) and Associated Risk Factors for Which Anticoagulation for the Prevention of LV Thrombus Might Be Considered

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DCM Risk factors associated with LV thrombus formation
Takotsubo syndrome V dysfunction with LVEF ≤30% and/or api-cal ballooning
Left ventricular noncompaction History of stroke or TIA2 and/or LV dysfunction
Peripartum cardiomyopathy Bromocriptine administration and/or LVEF ≤35%
Hypertrophic cardiomyopathy Apical aneurysm
Chemotherapy-related cardiomyopathy LV restrictive filling pattern and/or LVEF ≤30%
Cardiac amyloidosis AL type and/or LV restrictive filling pattern
Cardiomyopathy attributable to Chagas disease Apical aneurysm
Eosinophilic myocarditis Prior embolic episode

Table 3. Suggested Practical Management of Patients at Risk for or With LV Thrombus

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  • We suggest that CMR may be most appropriate when (1) there is the suggestion of a possible LV thrombus on echocardiogram but echocar-diography imaging even with an ultrasound-enhancing agent is not diag-nostic and (2) echocardiography does not demonstrate LV thrombus but a clinical concern remains (for example, cardioembolic stroke).
  • We suggest that, given the relatively weak data supporting prophylactic (pre-ventive) OAC in patients with acute anteroapical STEMI treated with reperfu-sion therapy (usually primary PCI) and anteroapical akinesis, any such consid-eration of OAC should weigh and incorporate the perceived risk of thrombus formation and bleeding and involve shared decision making. If OAC is initi-ated, a treatment duration might be 1–3 mo, depending on bleeding risk.
  • We suggest that, on the basis of reasonable study data, post-MI pa-tients with LV thrombus should be treated with OAC, typically for a duration of 3 mo.
  • We suggest that, given reasonably randomized data, patients with DCM should not be prophylactically treated with OAC, with the possible excep-tion of those with specific cardiomyopathies (for example, takotsubo syn-drome, LV noncompaction, eosinophilic myocarditis, peripartum cardiomy-opathy, and cardiac amyloidosis) with associated factors that increase the risk of LV thrombus formation, in which cases OAC could be considered.
  • We suggest that, on the basis of limited data, patients with NICM with LV thrombus should be treated with OAC for at least 3–6 mo, with dis-continuation if LVEF improves to >35% (assuming resolution of the LV thrombus) or if major bleeding occurs. There are insufficient study data to determine whether OAC should be continued indefinitely.
  • We suggest that, on the basis of limited data, it may be prudent to treat patients with OAC for newly diagnosed mural (laminated) LV thrombus as one would a patient with a protruding or mobile thrombus.
  • We suggest that, on the basis of supportive though insufficiently powered randomized data, in patients with LV thrombus, DOAC seems to be a rea-sonable alternative to warfarin.
  • We suggest that, on the basis of consensus opinion, in some patients with persistent LV thrombus, particularly a protruding or mobile thrombus, a trial of an alternative OAC or LMWH (for example, VKA if on DOAC, DOAC if on VKA with repeatedly subtherapeutic INR, LMWH if on VKA with therapeutic INRs) is not unreasonable. On the other hand, also on the basis of consensus opinion, discontinuation of OAC in patients with persistent mural (laminar) thrombus, particularly if the thrombus becomes organized or calcified, is not unreasonable.

Table 4. Factors to Assess and Reassess in Patients With LV Thrombus That Support the Continuation of OAC and Fac-tors That May or Do Not Favor Continued OAC

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Factors that favor continued OAC
  • Anteroapical MI with persistent akinesis
  • Protruding/mobile thrombus
  • Suspected or known cardioembolic event
  • Not high bleeding risk
  • Proinflammatory or hypercoagulable states
  • Recurrent LV thrombus

Factors that may or do not favor continued OAC
  • High bleeding risk
  • Concomitant antiplatelet therapy
  • Improvement in LVEF or focal akinesis
  • Persistent mural (laminated) thrombus, particularly if organized or calcified, despite therapeutic OAC

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Overview

Title

Management of Patients at Risk for and With Left Ventricular Thrombus

Authoring Organization

Publication Month/Year

September 15, 2022

Last Updated Month/Year

May 23, 2023

Document Type

Consensus

Country of Publication

US

Document Objectives

Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D018487 - Ventricular Dysfunction, Left, D016276 - Ventricular Function

Keywords

Left Ventricular Thrombus

Source Citation

Levine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, Shah ZI, Shenoy C, Spinler SA, Vallurupalli S, Lip GYH; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association. Circulation. 2022 Sep 15:101161CIR0000000000001092. doi: 10.1161/CIR.0000000000001092. Epub ahead of print. PMID: 36106537.

Supplemental Methodology Resources

Data Supplement