Cracking the clot: the RIVAWAR trial challenges warfarin’s reign in left ventricular thrombus post-acute coronary syndrome

Evidence before this study Left ventricular thrombosis (LVT) is a severe complication that often arises in patients with left ventricular systolic dysfunction, particularly within 1-14 days after a ST-segment elevation myocardial infarction (STEMI), and is associated with increased risks of stroke, embolization, and mortality. (1,2) Despite modern reperfusion therapy, the prevalence of LVT remains notable, ranging from 2-22%.(3,4) It is more frequent in patients with anterior STEMI and in patients with severe ventricular dysfunction and varies based on the imaging modality employed for detection.(5-7) Vitamin K antagonists (VKAs), such as warfarin, have been the standard treatment for LVT, though they require monitoring and have dietary interactions. (8)In contrast, direct oral anticoagulants (DOACs), including rivaroxaban, have gained attention as alternatives, offering advantages such as fewer food and drug interactions, a lower risk of bleeding, and no requirement for routine laboratory monitoring. (9) The 2023 ESC guidelines for management of acute coronary syndromes (ACS) recommend that oral anticoagulation therapy (warfarin or NOAC) should be considered for 3-6 months in patients with confirmed LVT (class IIa, level of evidence C). (10) Nonetheless, the evidence supporting NOAC use for LVT, particularly in the context of acute coronary syndrome (ACS), remains limited. (11,12) Contribution To Clinical Practice The RIVAWAR trial supports the use of rivaroxaban as a non-inferior alternative to warfarin for LV thrombus management, offering similar efficacy and safety with potential advantages in clinical practice.