Top Things to Know: Patients at Risk for and With Left Ventricular Thrombus
Published: September 15, 2022
Prepared by Anne Leonard MPH, BSN, RN, FAHA, – Senior Science and Medicine Advisor - Lead
- There is a paucity of information about how to manage patients at risk for or who have left ventricular thrombus.
- There are about one million myocardial infarctions (MI) each year in the United States. The incidence of left ventricular (LV) thrombus after anterior ST-segment elevation MI (STEMI) varies in different reports from 4-39% depending on the population studied, related timing and frequency of screening and the era (decade) of observation. The use of cardiac magnetic resonance imaging could have improved the outcomes in these studies.
- This scientific statement addresses clinical questions for the management of patients with LV thrombus which includes prevention and treatment after myocardial infarction (MI), prevention and treatment in dilated cardiomyopathy, management of mural or laminated thrombus, imaging of LV thrombus, direct oral anticoagulants in place of warfarin, treatments other than oral anticoagulants for LV thrombus and the approach to persistent LV thrombus despite anticoagulation therapy.
- The common understanding of LV thrombus pathophysiology (based on Virchow’s triad of thrombogenesis) assumes the interplay of three factors: 1) stasis due to reduced ventricular function, 2) endocardial injury, and 3) inflammation/hypercoagulability.
- Cardiac magnetic resonance imaging is the suggested imaging modality if a possible LV thrombus was detected following echocardiography or if the patient has experienced a cardioembolic stroke.
- Several clinical scenarios are described within this scientific statement and suggestions are made for the use of oral anticoagulant treatment in the setting of LV thrombus.
- Suggestions for the use of direct oral anticoagulants instead of vitamin K antagonists in the setting of LV thrombus in several clinical scenarios are discussed in this scientific statement.
- Factors that favor continued oral anticoagulation therapy as well as factors that may not favor oral anticoagulation therapy are described in this statement.
- Despite important advances in reperfusion therapy for acute MI, along with pharmacological and device treatment advances for patients with cardiomyopathy with reduced LV ejection fraction, LV thrombus continues to be a not uncommon and a challenging medical condition. Contemporary clinical trials are needed to understand the remaining uncertainty of the benefit of prophylactic anticoagulation in reducing the incidence of LV thrombus formation and whether it outweighs the risks in some clinical settings.
- The American Heart Association provides an updated scientific statement to assist in informing clinical care of patients with LV thrombus. This statement includes an overview of suggested strategies for the prevention and management of LV thrombus for the practicing clinician, offering several clinical scenarios to assist in decision making.
Citation
Levine GN, McEvoy JW, Fang JC, Ibeh C, McCarthy CP, Misra A, Shah ZI, Shenoy C, Spinler SA, Vallurupalli S, Lip GYH; on behalf of the 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 [published online ahead of print September 15, 2022]. Circulation. doi: 10.1161/CIR.0000000000001092