2026 Southeastern Residency Conference

 
Authors: Seana-Pierre Williams, Jaleesa Myers 
Wellstar Cobb Medical Center, Austell, GA 
 
Purpose: Left ventricular thrombus (LV thrombus) is a complication arising from left ventricular dysfunction, secondary to acute myocardial infarction or nonischemic cardiomyopathies. The current standard of care for the management of LV thrombus involves anticoagulation with warfarin, a vitamin K antagonist (VKA). While large-scale randomized controlled trials comparing the efficacy of direct oral anticoagulants (DOACs) to VKAs in this context are lacking, several retrospective analyses have demonstrated that DOACs may be non-inferior to VKAs with respect to mortality, incidence of stroke, and thrombus resolution. However, controversy remains regarding the off-label use of DOACs for this indication. The primary objective of this study is to evaluate the safety and efficacy of DOACs in comparison to warfarin in patients diagnosed with LV thrombus, and to assess anticoagulant prescribing patterns in the management of LV thrombus within Wellstar Health System.  
 
Methods: This study was a multicenter, retrospective chart review. Patients admitted to Wellstar Health System with a diagnosis of intracardiac thrombus (ICD-10 codes: I51.3 or I23.6), aged 18 years and older, and received either a DOAC (apixaban, rivaroxaban) or VKA (warfarin) for the management of LV thrombus were eligible for inclusion in this study. Data was collected from electronic medical records between January 1, 2023, and January 1, 2025. The target sample size was 100 patients, with 50 patients in each treatment cohort. Data was collected on the first 100 patients to meet the inclusion criteria within the specified time frame. The primary outcome of this study is the incidence of thromboembolic events, defined as recurrent left ventricular thrombus, stroke, or systemic embolism occurring within 90 days of treatment initiation. Secondary outcomes include left ventricular thrombus resolution within 90 days, hospital length of stay, incidence of bleeding events requiring blood transfusion within 90 days, and 30-day hospital readmission rates. 
 
Results: A total of 100 patients diagnosed with LV thrombus were included in this study. Fifty patients received warfarin and 50 received a DOAC. Of the patients prescribed a DOAC, 5 received rivaroxaban and 45 received apixaban. There was no statistically significant difference in the composite outcome of the incidence of thromboembolic events within 90 days between the warfarin and DOAC groups. There were no statistically significant differences between the warfarin and DOAC groups when comparing the rate of stroke (0% vs. 0%) and systemic embolism (2% vs. 4%). No recurrent LV thrombus within 90 days of treatment initiation were noted in either treatment groups. There were no bleeding events requiring blood transfusions within 90 days. The median length of hospital stay was 10 days (IQR 7–17) in the warfarin group versus 9 days (IQR 4–13) in the DOAC group with no statistically significant difference between groups. Thirty-day hospital readmission rates did not differ significantly between the groups.  
 
Conclusion: Based on the results of this study, DOACs may be as safe and efficacious as warfarin for the management of LV thrombus. This data underscores the importance of further large-scale, randomized controlled clinical trials to inform treatment decisions. Currently, the choice between warfarin and DOACs is informed by limited comparative data. However, both pharmacologic treatment options are used in clinical practice.