LV mural thrombus following STEMI : Welcome on board NOACs , they are safe…but, please don’t ask about efficacy !
January 21, 2026 by dr s venkatesan
Does DOACs trying to push over warfarin in post STEMI LV mural thrombus ?
Yes , it seems so. Old must give way for new even if it is gold. New is trendy. Only thing we need to prove is, whether it is safe . Just don’t bother about efficacy. Every one of us know Warfarin is many-fold effective. But, still NOACs are coming in a big way. With the help of big trials NOACS will ultimately replace the much dangerous, bleed prone Warfarin. One more reason we might embrace the inferior drug is , the clinical Inertia for vigilant INR monitoring.
What does the evidence say ?
Read : Ref 1
The future of medicine will be fight between quality & ( Intention ) of evidence and experience
Caution : Personal opinion
It would be science at its best, when a less potent drug, that requires zero monitoring, will replace a more potent and established OAC. It doesn’t require brilliant brains, to realize a drug which has less bleeding risk, is going to be less effective in getting rid of thrombus as well. (The trial in Ref 1 proved otherwise)
Only issue with warfarin is, we need to be a little more careful. Fortunately, its usage in LV mural thrombi is not likely to be permanent. (as in prosthetic valve)
Reference
A new pre specified -meta-analysis (I don’t know what it means) from a popular Journal EuroIntervention shows a strong evidence in favor for DOACS
1.Jenab Y, Sadeghipour P, Mohseni-Badalabadi R, Kaviani R, Hosseini K, Pasebani Y, Khederlou H, Rafati A, Mohammadi Z, Jamalkhani S, Talasaz AHH, Firouzi A, Ariannejad H, Alemzadeh-Ansari MJ, Ahmadi-Renani S, Maadani M, Farrashi M, Bakhshandeh H, Piazza G, Krumholz HM, Mehran R, Lip GYH, Bikdeli B. Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials. EuroIntervention. 2025 Jan 6;21(1):82-92. doi: 10.4244/EIJ-D-24-00527. PMID: 39773831; PMCID: PMC11684328.
In the above study, Warfarin trails behind Rivaroxaban by a huge 20% margin in it’s ability to successfully remove LV thrombus.
TThere is a surprise in the conclusion : Why do the authors, hesitate to commit DOACS are superior? Something to think about.
