The Efficacy and Safety of Direct Oral Anticoagulants Compared to Warfarin for Left Ventricular Thrombus Resolution

<b>Background and Aim:</b> Left ventricular thrombus (LVT) is a common complication of myocardial infarction (MI) and heart failure with reduced ejection fraction (HFrEF), typically managed with vitamin K antagonists (VKAs) for up to six months. However, data on direct oral anticoagulants (DOACs) for LVT treatment remain limited and conflicting. This study evaluates the effectiveness and safety of DOACs compared to warfarin for LVT resolution. <b>Methods</b>: We conducted a single-center retrospective cohort study of consecutive patients diagnosed with LVT from January 2010 to May 2024. The primary outcome was LVT resolution at 24 months. Safety outcomes included major bleeding and thromboembolic events. Diagnosis and follow-up were performed via echocardiography, with cardiac magnetic resonance and computed tomography as needed. Anticoagulant type, dose, duration, and concurrent antiplatelet therapy were at the treating physician's discretion. <b>Results</b>: Among 171 patients (82.5% male, mean age 59.8 ± 14.7 years), 99 received DOACs and 72 received warfarin. LVT resolution was higher with DOACs (66.7% vs. 50%, HR 2.0, 95% CI 1.07-3.73, <i>p</i> = 0.029), with a trend toward faster thrombus resolution (185 vs. 220 days, <i>p</i> = 0.214) though statistically not significant. DOAC use remained an independent predictor of LVT resolution, regardless of antiplatelet use. Major bleeding (2.9%), thromboembolic events (5.3%), and mortality (5.3%) were similar between groups. <b>Conclusions</b>: DOAC therapy was associated with higher LVT resolution rates and a comparable safety profile to warfarin. Further randomized clinical trials are warranted to validate these findings.